Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bone Cancer
Treatment: Home Health Care
The health plan denied the requested Consumer directed personal assistant program (CDPAP) 8 hours per day, 7 days per week for a total of 56 hours as not medically necessary. The health plan's determination is overturned. 

This case review is for a male with a medical history of Ewing sarcoma. The patient was approved for 3 hours per day, 3 days per week (9 hours per week) of consumer directed personal assistant program (CDPAP). The patient and his care team requested an increase to 8 hours per day, 7 days per week (56 hours per week).

A letter of medical necessity from the patient's nurse practitioner states that the patient has Ewing sarcoma that has metastasized to his lungs. He had surgical resection and is in the course of a 6-month chemotherapy regimen. Chemotherapy has left him with neuropathy, chronic pain, constipation, urinary symptoms, dizziness, reduced mobility, and frequent falls. He is unable to walk without human assistance and a walker. He cannot independently perform many activities of daily living (ADL) and instrumental activities of daily living (IADL).

A community advocate provided a letter of support for this appeal. The letter states that the patient lives by himself. He has chemotherapy induced pain, nausea, and vomiting. He wears diapers for incontinence and is unable to change himself. He needs assistance with food preparation, showering, dressing, and medication administration. He does not have enough help at home with these tasks and has no help on the weekends.
A Uniform Assessment System (UAS) was completed. The review was conducted because the patient had had recent falls and requested additional help with shopping, dressing, cooking, laundry, transportation, and bathing. The UAS states that the patient lives with his wife, daughter, and son and is home alone for about 6 hours per day (in contradiction to the letter which states he lives alone). The patient was alert and oriented times three; recall was 2/3 after five minutes. He is able to perform procedural tasks and direct his own care. For his IADLs, he requires total dependence for meal preparation and housework. He requires maximal assistance for transportation. The assessment states he is independent in managing medications. For his ADLs, he requires extensive assistance for bathing and dressing only. Other ADLs are listed as independent (in contradiction to his provider's letter of medical necessity). At the time of the review, the patient ambulated slowly without any assistive device or human assistance. He was able to groom himself and negotiate one flight of steps. He bathes twice per week with assistance from his wife. His wife and daughter handle shopping. He was using the toilet independently. He was continent of stool and urine (in contradiction to the letter from the community advocate).

The health plan's determination of medical necessity is overturned, in whole, as the requested health service of Consumer directed personal assistant program (CDPAP) 8 hours per day, 7 days per week for a total of 56 hours is medically necessary for this patient.

Information provided in the UAS regarding the patient's functional status is contradictory to the information provided in the physician and advocacy letters. The UAS is now approximately 4 months old, and the letters are more recent. The letters describe challenges with all transfers, toileting, locomotion, and activities of daily living. The patient's condition can be expected to decline, given the nature of stage 4 cancer, so it is reasonable to assume that his condition may have deteriorated since the last assessment was completed. Assuming this is the more accurate reflection of his current functional status, the increase in CDPAP hours is medically necessary.