Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Early onset dementia, blindness
Treatment: Consumer Directed Personal Assistance Program (CDPAP) services, 12 hours/day, 7 days/week, total of 84 hours/week
The insurer denied coverage for CDPAP services, 12 hours/day, 7 days/week, total of 84 hours/week.
The denial is overturned.

This adult female has functional impairment associated with various medical conditions and needs help with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives alone. She receives personal care services, provided as Consumer Directed Personal Assistance Program (CDPAP). The patient advocate's external appeal letter indicates CDPAP aide is the patient's granddaughter. As per the more recent Uniform Assessment System (UAS), a granddaughter is noted as the only informal helper (it is not clear if this is the same granddaughter as CDPAP aide). The patient receives CDPAP services 36 hours/week. As noted in the UAS and insurer's final denial letter, the patient expressed a need for more help with daily activities. She requested (via designee) increase of CDPAP services to 84 hours/week, which was denied. An external appeal was requested. 

The functional status report for IADLs indicates the patient was totally dependent for ordinary housework; she needed maximal assistance for meal preparation, managing medications and finances, stairs, shopping, transportation; setup help for phone use. For ADLs, the patient needed maximal assistance for bathing, walking, locomotion, transfer toilet; extensive assistance for dressing lower body; supervision for personal hygiene, dressing upper body, toilet use; setup help for bed mobility, eating.

For a person with dementia, loss of ability to perform daily activities is an expected consequence as cognitive impairment progresses. Cognitive ability for IADLs generally declines before ADLs, as IADLs require a higher level of cognitive function. Cognitive ability for ADLs is usually preserved until later stages of dementia. The patient has significant physical and sensory impairments that limit her ability to perform IADLs, but with report of memory loss and some confusion, cognitive decline has probably affected some IADLs such as managing medications and finances (e.g. ["for example"], UAS indicates the patient needs reminders for medications). It is likely that the patient's physical and sensory impairments are the primary cause of her need for assistance with ADLs, but impaired memory and decision-making can affect safety during ADL performance. Cues, reminders, prompting are part of the scope of care for personal care/CDPAP aides when providing assistance with daily activities.

The nurse practitioner's letter indicates that the patient has been totally blind for the last few years. The UAS reported the patient has no vision. The UAS includes diagnosis of glaucoma, but there are no medical records available that fully describe the patient's loss of vision. The UAS indicates that vision loss adversely affects the patient's ability to perform most daily activities, requiring various types of help, including assistance, supervision, setup help. 

Recommendation is given to approve CDPAP services, 12 hours/day, 7 days/week, total of 84 hours/week.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for CDPAP 12 hours/day, 7 days/week, a total of 84 hours/week services is substantiated.