Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebrovascular accident (CVA)
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week 
The insurer denied: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week 
The denial is: Overturned

The patient is a male with past medical history of cerebrovascular accident (CVA) with left-sided hemiplegia, osteoarthritis, dementia, bowel incontinence, urinary incontinence, hypertension, and hyperlipidemia who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 10 hours/day, 7 days/week to total 70 hours/week based on assessment performed which assessed the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, shopping, personal hygiene, dressing lower body, locomotion, and toilet use while maximum assistance with tasks of stairs, transportation, bathing, dressing upper body, walking, and transfer toilet. With tasks of bed mobility and eating the patient was assessed at extensive assistance. The subject under review is the medical necessity for Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week for this patient.

The health plan's determination is overturned.

The requested CDPAP hours are medically necessary for this patient.
The patient had a significant change in functional status and cognitive status following CVA with left hemiplegia. The patient's medical provider documented medical necessity of increased services and the need for durable medical equipment (DME) and skilled nursing services. Per the patient's niece's letter, the patient had not received DME and skilled nursing services and the assessment was inaccurate. The plan's assessment noted the patient had no participation in bed mobility and the patient had new documented bowel and bladder incontinence with the inability to transfer toilet and use toilet without toilet assistance. The patient requires total assistance with all activities of daily living (ADLs)/instrumental activities of daily living (IADLs) except for eating. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet the patient's unscheduled and unpredictable care needs. The plan should not have utilized a task based assessment to calculate the patient's hours as he has documented 24 hour care needs. The patient's care needs in the overnight hours are such that a CDPAP would not be able to obtain at least 5 hours of uninterrupted sleep. The patient's care needs are not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours 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 his own home.