Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 7 hours per day- 7 days per week- a total of 49 hours per week. 
The denial is overturned. 

The patient is a female with past medical history of osteoarthritis, spinal stenosis, Alzheimer's dementia, urinary incontinence, bowel incontinence, hypertension, hyperlipidemia, and diabetes mellitus type 2 with neuropathy who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 4 hours/day, 7 days/week to total 28 hours/week. The patient was seen by a neurologist due to right leg pain, right leg weakness, multiple falls, and worsening memory with the recommendation for additional testing. 
The patient underwent an magnetic resonance imaging (MRI) of the lumbar spine showing small central disc protrusion indenting the thecal sac at lumbar (L)1-2, loss of disc space height and small left paracentral disc herniation indenting the thecal sac with mild central canal stenosis at L2-3, grade one spondylolisthesis with unshelving of the disc flattening the ventral thecal sac encroaching upon the neural foramina bilaterally with moderate to marked spinal stenosis at L3-4, marked loss of disc space height with endplate osteophyte and disc bulge encroaching upon the neural foramina bilaterally, left greater than right with impingement upon the descending left L5 nerve root in the lateral recess with mild spinal stenosis at L4-5, and diminutive disc space with marked tapering of the thecal sac at this level of secondary to epidural fat. 
The patient was hospitalized for surgery for spinal stenosis. There was a request to increase CDPAP services. 
At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP) Services: 7 hours per day- 7 days per week- a total of 49 hours per week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP) Services: 7 hours per day- 7 days per week- a total of 49 hours per week is medically necessary for this patient.
There is documentation from the patient's medical provider of worsening cognitive and physical functioning. The patient has documented care needs with all ADLs and Instrumental activities of daily living (IADL)s. The plan's own assessments client tasking sheet estimated care needs at 49 hours and 52.5 hours. The patient requires maximum assistance with transfer to the toilet and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The plan assumed the patient had informal help outside of all of the hours of CDPAP services. The patient's care needs cannot be met solely with medical equipment and adaptive supplies. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 7 hours/day, 7 days/week, to total 49 hours/week 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 her own home.
Therefore, the requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP) Services: 7 hours per day- 7 days per week- a total of 49 hours per week is medically necessary.