Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, Degenerative Joint Disease
Treatment: Consumer Direct Personal Aide Service (CDPAS) 6 days x (times) 9 hours 
The insurer denied coverage for Consumer Direct Personal Aide Service (CDPAS) 6 days x 9 hours.
The denial is overturned.

This case involves a patient diagnosed with osteoporosis, hyperlipidemia, agitated depression, hypertension, venous insufficiency, gastroesophageal reflux disease (GERD), trigeminal neuralgia, degenerative joint disease, urge incontinence, and gait instability who was being recommended for 54 hours/week of personal assistant services.  The indication was that the patient would benefit from increased home care hours for assistance in dressing, bathing, cooking, and meal preparation along with shopping, laundry, bathing, and assistance/supervision with toileting and incontinence supplies. The treating physician stated the patient sustained several falls at home, which included the need for emergency room (ER) visits.  The patient also sustained severe burns to their thighs and buttocks after showering in water that was too hot.  The most recent progress note reiterated the patient's medical history.  The patient's medication was increased to gabapentin 300 milligrams (mg) - 600 mg - 600 mg (1500mg/day) and carbamazepine 40mg 2 times daily with only partial relief and some issues with daytime drowsiness.  The patient had occasional urge incontinence with progressively frequent episodes sometimes without warning until the patient is voiding.  The patient wears incontinence diapers continuously but is still taken to the bathroom for prompted voiding with partial control of symptoms.  The patient is unable to remove or replace diapers and therefore requires around-the-clock assistance with toileting. The patient's balance had declined, and they ambulated using a rollator but needed close supervision with ambulation. The physician noted the patient had 1 fall without injury and stated the patient was independent with eating but required assistance for shopping, cooking, cleaning, and laundry. The patient is no longer able to dress themselves due to coordination issues.  Objectively, the patient was otherwise in no distress. This review pertains to consumer directed personal aide service (CDPAS) 6 days x (times) 9 hours.

Personal assistant services (PAS) allow patients to remain in the comfort of their own home to receive care/treatment rather than residing in a skilled nursing facility, long-term acute care, or assisted living.  The documentation provided for the review noted the patient was of an advanced age and had multiple medical issues that affected their functionality.  The physician recommended personal assistant services hours at a total of 54/week.  This was to assist the patient with completing activities of daily living and instrumental activities of daily living.  After a review of the provided documentation, it was determined that the requested services were appropriate and within the standard of care.  As such, the request for Consumer Direct Personal Aide Service (CDPAS) 6 days x (times) 9 hours is medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Direct Personal Aide Service (CDPAS) 6 days x (times) 9 hours is substantiated.