Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: CDPAS 24 Hours of Continuous Care
The insurer denied the CDPAS 24 hours of continuous care.
The health plan's determination is overturned. 

The patient is a female with a past medical history of parkinson's disease, obstructive sleep apnea, tremors, obesity, hypertension, anxiety, spinal stenosis, chronic obstructive pulmonary disease, glaucoma, gastroesophageal reflux disease, diabetes mellitus type 2, coronary artery disease, osteoarthritis, anemia, oxygen dependence, urinary incontinence, and bowel incontinence who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services for 49 hours per week. The patient was hospitalized following a fall and was subsequently transferred to rehabilitation. The patient had a cardiology follow up with office notes stating the patient had chronic exertional shortness of breath (SOB), could not walk with a walker due to leg weakness and falls, and there were no medication changes.

The patient underwent a video assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and managing finances while maximum assistance with tasks of managing medication, phone use, stairs, shopping, transportation, equipment management, bathing, dressing upper body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at extensive assistance with tasks of personal hygiene and dressing upper body while limited assistance with tasks of bed mobility and eating. Overnight care logs documented the patient's care needs at least every 4 hours. On 1 evening there was a span of 6 hours where the patient did not need assistance; however, the other 2 evenings, the patient required assistance needs with activities of daily living (ADL) at least every 4 hours. The patient's provider stated the patient's tremors hindered her from eating and administering medication, her prognosis was fair, the patient needed help with glucose monitoring, and she needed assistance with all daily activities due to poor range of motion, shortness of breath with exertion, and weakness. The patient's caregiver stated the patient's dementia had gotten worse, she was unable to prepare meals, she was unable to remember how to use the phone to dial 911, she laid awake most of the night, had frequent incontinent episodes overnight if not reminded to go to the bathroom, and had gotten out of her home on her own and was sitting outside.

At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS) 24 hours of continuous care.
I overturn the health plan's determination, in whole.

The requested CDPAS 24 hours of continuous care is medically necessary.

There is documentation from the overnight care logs that the patient needs assistance with ADL at least every 4 hours which would not allow a patient care assistant (PCA) at least 5 hours of uninterrupted sleep. On one of the evenings, the patient required ADL needs every 3 hours. The patient has unpredictable and unscheduled care needs that span a continuum of time, and the insurer failed to document a plan to meet the patient's care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADL and instrumental activities of daily living. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 24 hours per day, continuous are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.