Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Panic Disorder, Major Depressive Disorder-recurrent, agoraphobia, severe anxiety when outside the home
Treatment: consumer directed personal care assistance (CDPAS)
The insurer denied coverage for: consumer directed personal care assistance (CDPAS)
The denial is: Upheld
This is an adult patient who reportedly had a diagnosis of Panic Disorder and Major Depressive Disorder-recurrent and also had agoraphobia and severe anxiety when outside the home. The patient reportedly was confined to home and socially isolated. It was reported that the patient was struggling with some activities of daily living (ADL) including preparing meals, shopping, cleaning and the request was for home care services to assist in some of these areas. It was reported that his mother died 2 months prior and that the patient did not know how to cook, clean, wash things, and was nervous when leaving the house. The patient reportedly was in mental health treatment in weekly therapy and had medication management also. He reportedly had past hospitalizations as a teenager but not since. The patient was living alone and was in the same home address for the past 5 years. It was reported that the patient's nephew helped with with shopping, cooking, and cleaning. The request was for Consumer Directed Personal Care Assistance (CDPAS).
 
The medical records provided for review did not document enough specific evidence to support that it was considered medically necessary for the patient to have these services. According to FOCUS: The Lifelong Journal in Psychiatry: Anxiety Disorders Summer 2004 Volume II Number 3, it states that for patients with anxiety disorder cognitive behavioral therapy, pharmacotherapy, and other psychotherapies were indicated and also have been shown to result in reduction of symptoms. This patient was a candidate for outpatient mental health psychotherapy or pharmacotherapy due to anxiety symptoms of agoraphobia, so weekly individual psychotherapy and medication management was considered standard and appropriate treatment and medically necessary treatment. However, there was not enough specific evidence in the medical records to support that this patient required Consumer Directed Personal Care Assistance (CDPAS). 

In this case this patient did not have reported difficulties ambulating, bathing, showering, brushing his teeth, and reportedly had some independence with ADL's. It was reported that he was independent with toileting and eating, using phones, personal  hygiene, had bed mobility, was able to transfer off toilets, was able to manage his own finances, walked independently in doors, was able to verbalize, had no short-term memory deficits, was self-directing for needs and making decisions, was able to verbalize an emergency plan, was able to express his ideas without difficulties, had clear comprehension, had no difficulty in normal conversation, was able to answer and understand questions, was alert and oriented times 3, and there were no reports of severe mood or behavioral symptoms, hallucinations, delusions, or abnormal thoughts. It was reported that he required assistance with cooking, shopping, and cleaning but this did not require Consumer Directed Personal Care Assistance (CDPAS). 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Consumer Directed Personal Care Assistance (CDPAS) is not substantiated.