Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's Disease
Treatment: Customer-directed Directed Personal Assistance Services (CDPAS) 7 days per week 2-12 hours split shift (168 hours per week)
The insurer denied Customer Directed Personal Assistance Services (CDPAS) 7 days per week 2-12 hours split shift (168 hours per week).  The determination is overturned. 

The patient is a female with a past medical history of Parkinson's disease, frontotemporal dementia, paroxysmal atrial fibrillation (A-fib), chronic anticoagulation, mitral valve prolapse, congestive heart failure (CHF), hypertension, hyperlipidemia, cerebrovascular accident (CVA), vertebral fractures, overactive bladder, urinary incontinence, gastroesophageal reflux disease (GERD), hiatal hernia, hypothyroidism, glaucoma, anxiety, and depression who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 7 days/week with 2, 12-hour shifts, to total 168 hours/week based on video assessment performed. The patient was assessed at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, and shopping while maximum assistance with tasks of phone use, transportation, bathing, dressing upper/lower body, transfer to the toilet, toilet use, and bed mobility. With tasks of managing medication, personal hygiene, walking, and locomotion, the patient was assessed at extensive assistance while limited assistance with task of eating. Notes stated the patient lived alone.

A home physical therapy note stated the patient was unable to ambulate long distances with a rollator, could not stand more than 5 minutes with loss of balance, and was unable to do activities of daily living (ADL)s independently.

The insurer sent final adverse determination notice to reduce, suspend, or stop services, stating CDPAP services would be reduced to 56 hours/week. The denial stated the patient did not have a medical condition that required turning and repositioning every 2-3 hours and the patient did not need someone to be awake to care for her all night long.
The patient's neurologist provided a letter requesting an increase in personal care services as medically necessary and in order to meet all of the patient's personal care needs. The letter stated the patient lived alone and had no formal or informal support to provide her with assistance or to meet the patient's personal care needs and help her complete her activities of daily living.

At issue is the medical necessity of Customer Directed Personal Assistance Services (CDPAS) 7 days per week 2-12 hours split shift (168 hours per week).

The requested health service/treatment is medically necessary for this patient.
Her provider noted the patient requires and it was medically necessary to have turning and repositioning every 2 hours, as the patient was not able to reposition herself in bed. In addition, the daughter reported the patient has had episodes of vomiting, which have been unpredictable, and the patient requires assistance to sit up to prevent aspiration. Therefore, the patient's care needs in the overnight hours would not allow a personal care aid (PCA) 5 hours of uninterrupted sleep. The patient also has unpredictable and unscheduled care needs in the overnight hours and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The family is unable to provide formal or informal support. The patient's care needs cannot be met solely with adaptive equipment or medical supplies. 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.