Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis; gait abnormality, s/p tibia fracture

Treatment: Consumer directed personal care assistance services (CDPAS) 20 hours per week

The insurer denied coverage for consumer directed personal care assistance services (CDPAS) 20 hours per week. The denial was reversed.

This patient is a male with medical history including: back pain, sciatica, gait abnormality, s/p tibia fracture, and osteoarthritis. As a result of these medical conditions, the patient's functional capacity has declined; most likely due to chronic pain. Considering pain is affecting patient's back and lower extremities, weight bearing activities are probably affected the most. It is also noted that patient has osteoarthritis, and he is obese (BMI 31.6) which places him at higher risk for osteoarthritis of lower extremities (especially knees).

Although the UAS indicates the patient needs only supervision for walking, and is independent with transfers, the patient's ability to safely transfer and ambulate without assistance raises some concerns. The UAS identifies patient has pain daily, unsteady gait, difficulty standing up unassisted; foot problems that limit walking, and slow gait speed (19 seconds /4 meters). It was noted in the UAS-ATSP Summary of Hours Recommended that patient was requesting home attendant services because of limited ability to stand for a long time due to chronic pain. The patient may be physically able to walk slowly with unsteady gait, with a walker and with supervision only; but this is not necessarily safe, and may place additional strain on his back and legs. Symptoms from arthritis and sciatica can fluctuate in severity, and there may be times when the patient needs hands on assistance to relieve some of the weight-bearing stress of walking and other weight-bearing activities.

UAS indicates patient has difficulty at times standing up unassisted, which suggests he may have difficulty at times getting up from the toilet. The UAS identified transfer toilet as independent with set up help; but when patient has pain in his back and lower extremities he may need some assistance getting up from the toilet. UAS indicates patient needs supervision for bathing. Bathing requires various upper and lower body maneuvers (even if he has a shower chair), which raises the question of whether he needs assistance with bathing. 

Musculoskeletal and neuropathic disorders contribute to significant disability.  This patient has multiple conditions (arthritis, sciatica, s/p tibial fracture) and multiple sites of pain (back, lower extremities), which increases the risk of functional impairment, decreased mobility and loss of independence. Various treatment plans can be effective (e.g. medication, rehabilitation services); but as symptoms worsen and become chronic, people often need some level of assistance with daily activities.

The insurer's final determination letter indicates the patient is requesting CDPAS 20 hours per week; the insurer approved CDPAS 10 hours per week.

Twenty hours of assistance per week for a person with chronic pain that limits his routine mobility is not excessive; The daily allocation of hours should be based on availability of informal caregivers (none were noted in the early-2019 UAS; this may have changed) and any specific needs of the patient for certain days of the week. Re-assessment will determine whether CDPAS 20 hours per week is adequate to meet the patient's needs.

The requested service is medically necessary. The health plan did not act reasonably

Based on the above, the medical necessity for consumer directed personal care assistance services (CDPAS) 20 hours per week is substantiated.  The insurer's denial is reversed.