Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident (CVA)
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Live-in per diem 1 day- 7 days for a total of 7 days per week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Live-in per diem 1 day- 7 days for a total of 7 days per week.
The determination is overturned.

This is a patient with a medical history notable for congestive heart failure, cognitive impairment, spinal fractures, recent embolic stroke, and bed bound status. The patient is approved for 6 hours per day, 7 days per week (total of 42 hours per week) of Consumer Directed Personal Assistance Program (CDPAP). Her care team requested an increase to live-in per diem 7 days per week CDPAP. This request was partially denied by the insurance company; they approved an increase to 7.5 hours per day, 7 days per week (52.5 hours per week).

A letter of medical necessity for this appeal was provided by the treating physician. The letter states that she has declined physically and cognitively since her recent hospitalization. She is oriented only to person and confuses people around her. She requires human assistance for transfers and activities of daily living (ADL)s.

A Uniform Assessment System (UAS) was completed and was available for review. The patient showed modified independence in cognition. She was alert and oriented times three and had 1/3 five-minute recall. From a functional standpoint, she requires total dependence for housework, transportation, and stairs. She requires maximal assistance for meal preparation, managing finances, managing medications, and shopping. For her ADLs, she requires total dependence for bathing and toilet use. She requires maximal assistance for hygiene, dressing upper/lower body, walking, locomotion, toilet transfer, and bed mobility. She requires extensive assistance for eating. She is frequently incontinent of urine and infrequently incontinent of stool. She uses pull ups. Compared with a prior assessment, she showed a decline in function across multiple domains. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP) Live-in per diem 1 day- 7 days for a total of 7 days per week 

The requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP) Live-in per diem 1 day- 7 days for a total of 7 days per week is medically necessary for this patient.

The patient relies on caregiver help for all ADLs and Instrumental activities of daily living (IADLs). She has regressed significantly after her recent embolic stroke. She lives alone in her apartment. She has incontinence and relies on assistance for toileting and changing after episodes of incontinence. These personal care tasks cannot be scheduled to take place during specific personal aide hours. It is medically necessary for her to receive personal care assistance throughout the day and night to allow her to have her personal care needs be met. Her imaging shows multiple chronic vertebral fractures and other bony hematomas, although she does not report trauma. It is concerning that she may be attempting to perform activities without assistance which could be resulting in injury. This would be a concern if she did not receive an increase in home health hours.