Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiopulmonary diseases and osteoarthritis.
Treatment: Consumer Directed Personal Assistance Program (CDPAP) services of 8 hours per day, 7 days per week for a total of 56 hours per week.

The insurer denied coverage for CDPAP services of 8 hours per day, 7 days per week for a total of 56 hours per week.  The denial is overturned.

This is a female patient who has an extensive medical history associated with functional impairment. The patient needs assistance with most daily activities and she receives personal care services through Consumer Directed Personal Assistance Program (CDPAP); 35 hours per week. She lives with her husband and receives some informal help from family. The patient is oxygen dependent. An increase of CDPAP services to 56 hours per week was requested.

Uniform Assessment System (UAS) documentation was provided for review. The functional status report indicates the patient is totally dependent or needs maximal assistance with household related tasks, meal preparation, stairs and shopping. She needs extensive assistance with finances and medications. Phone use is noted as setup help. For activities of daily living (ADLs), the patient needs extensive assistance with bathing, personal hygiene and dressing; all other ADLs are noted as limited assistance. The UAS assessment of cognition indicates the patient has some difficulty with decisions and memory in new situations; she is self-directing; oriented x 3. It is noted that she needs extensive assistance with finances and medications which may suggest some degree of cognitive impairment; but there is limited information as to whether assistance for these tasks is needed due to impaired physical or cognitive function (or both). Based on available information, it appears the patient's functional decline with daily activities is most likely due to physical impairment.

The patient's respiratory status is significantly compromised by several pulmonary and cardiac conditions including: Idiopathic pulmonary fibrosis (IPF); Asthma; Heart failure; Pulmonary hypertension (PH). The co-existence of these cardiopulmonary diseases has a cumulative adverse effect on the patient's functional status. The patient is oxygen dependent, with impaired ability for most physical activity. It is likely that her activity tolerance may vary depending on the acuity of symptoms. However, it appears the patient needs assistance for all mobility related activities throughout the day, which includes walking, transfers and toileting; so, a caregiver needs to be available most of the day. In addition to cardiopulmonary disease limiting the patient's functional ability for daily activities, she also has osteoarthritis which limits physical function through joint pain, stiffness and decreased range of motion.

The patient needs assistance with ADLs and instrumental activities of daily living (IADLs) at various times from morning until evening. The request for increase of services is for 56 hours per week, 8 hours per day. With CDPAP services, hours can be split to maximize assistance to the patient during hours when informal caregiver assistance is not available. Optimal CDPAP aide schedule can be determined with the patient and family. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Program (CDPAP) services of 8 hours per day, 7 days per week for a total of 56 hours per week is overturned. Medical necessity is substantiated.