Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Consumer Directed Personal Assistance Services (CDPAS) from 35 hours to 49 hours/week
The insurer denied CDPAS from 35 hours to 49 hours/week.
The determination is overturned.

This is a female patient with a past medical history of osteoarthritis, bladder incontinence, hypertension, coronary artery disease, atrial fibrillation, congestive heart failure, osteoporosis, hyperlipidemia, and permanent pacemaker who had been assigned Consumer Directed Personal Assistant Program (CDPAP) services 35 hours/week based on assessment tool.

Notes from the assessment stated the patient lived with her child, had a fall and was diagnosed with transient ischemic attack (TIA), had a decline in activities of daily living (ADLs) status over the last 90 days, had deterioration of overall self-sufficiency in the last 90 days, and had difficulty with tasks related to pain and numbness in her lower extremities. Tasking tool estimated 27.83 hours/week. There was a request to increase CDPAP services and the patient underwent another assessment. 

Notes from the assessment stated the patient was residing in a nursing home/rehabilitation facility, had a decline in ADLs status over the last 90 days, had a deterioration of overall self-sufficiency in the last 90 days, was frequently incontinent of urine, had "strong family support," but also noted to have no informal help. Tasking tool estimated 34.00 hours/week. 

The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's medical diagnoses, noted the patient's recent thoracic surgery with limited movement since the surgery with increased assistance needs with ADLs, and strongly recommended patient to have 12 hours/day, 7 days/week of homecare. The denial stated the patient had been reassessed, and the authorized hours were adjusted accordingly and were currently authorized and the amount, duration, and scope necessary to meet the patient's personal needs and hours beyond those currently authorized would be for safety monitoring which was not a covered benefit. The patient and family appealed the denial decision. At issue is the medical necessity of an increase in Consumer Directed Personal Assistance Services (CDPAS) from 35 hours to 49 hours/week.

The services are medically necessary.

There is documentation from the patient's PCP of medical necessity of increased consumer directed personal care services. There is documentation assessment of a decline in ADL status and deterioration of overall self-sufficiency in the last 90 days however the assessment showed an improvement in tasks of phone use, personal hygiene, walking, locomotion, transfer toilet, toilet use, and bed mobility indicating the assessment underestimated the patient's care needs. The patient has no informal help per the assessment and therefore requires assistance outside of the time she has formal help. The requested increase in CDPAP services cannot be met solely with adaptive equipment and medical supplies. 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 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.