Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, Rheumatoid Arthritis, Fibromyalgia

Treatment: consumer directed personal assistance services (CDPAS) 7 days per week, 2-12 hours split shift (168 hours per week)

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 7 days per week, 2-12 hours split shift (168 hours per week)

The denial is upheld

This is a patient with chronic medical problems including diabetes, heart disease, kidney disease and rheumatoid arthritis.  The patient lives with their spouse.  The plan decreased her consumer directed personal assistance services (CDPAS) from 168 hours/week (split-shift) to a live-in 7 days/week.  The patient is seeking re-instatement of the (split shift) CDPAS 168 hours per week.   

The patient's cognitive skills are described as minimally impaired  The patient is "able to make needs known.  Member able to activate Personal Emergency Response System (PERS), able to call for help for 911."  The patient is reportedly totally dependent to maximal assistance for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing, lower body dressing, toilet transfer/use, locomotion and ambulation (uses a walker).   Limited assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility and eating.   The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel.  

The letter from the patient's treating physician noting reported clinical deterioration was reviewed.  The physician did not provide associated treatment notes.  There has been a decrease in mobility (locomotion and ambulation) from limited assistance to extensive assistance when compared to the Uniform Assessment System (UAS( report.   However, there has been no change in the patient's ADL status, self-sufficiency or reported falls over the prior 90 days.   In addition, and according to the physical therapy note, the patient was able to ambulate household distances (50 feet) with "contact guard-minimal" assistance and a rolling walker.  

The patient's condition and functional deficits are not at a level or unpredictable as to require the requested CDPAS-7 days per week, 24 hours per day (continuous care by more than one person) 168 hours per week.  This physician would agree the patient may benefit from monitoring for safety; particularly due to the patient's reported weakness and falls risk.  CDPAS for companion care or safety supervision without the direct provision of activities of daily living (ADL) task assistance is not a covered service.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the approved (live-in) CDPAS 7 days per week, shared household responsibilities of other adult living in the home, and informal care from family and Personal Emergency Response System (PERS).  

From a physical medicine and rehabilitation perspective, the requested Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 24 hours per day(split shift) 168 hours per week is not medically necessary.   

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 assistance services (CDPAS) 7 days per week, 2-12 hours split shift (168 hours per week) is not substantiated.