Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Paraplegia, wheelchair dependence, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, and traumatic fracture

Treatment: Consumer directed personal assistance services (CDPAS) 60 hours per week

The insurer denied coverage for CDPAS 60 hours per week

The denial is overturned

This adult male has functional impairment associated with several medical conditions and needs help with most daily activities. He relies on assistance from personal care services, provided as CDPAS. As per the recent Uniform Assessment System (UAS) report, the patient's brother is the CDPAS aide. The patient has been receiving CDPAS 50 hours per week. Request was made for increase of CDPAS to 60 hours per week, which was denied. 

The functional status report for instrumental activities of daily living (IADLs) indicates patient needs maximal assistance for meal preparation, ordinary housework, stairs, shopping, transportation; limited assistance for managing medications and finances, phone use. For activities of daily living (ADLs) the patient needs extensive assistance for bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use; limited assistance for personal hygiene, dressing upper body; setup help for bed mobility, eating.  

The patient needs some type of help with all daily activities, which is reflected in the UAS functional status report. The patient needs extensive (weight-bearing) assistance with toilet transfer and toilet use. This is consistent with the patient's history of leg weakness and knee instability (difficulty with transfers); upper extremity joint symptoms (limited ability with cleaning/hygiene due to decreased upper extremity range of motion (ROM) and impaired hand function) and decreased ROM of spine/difficulty bending (clothing adjustment). The UAS also reports the patient has frequent urinary incontinence and occasional bowel incontinence. The patient needs extensive assistance with incontinence care, including cleaning/hygiene and changing incontinence supplies. The need to use the toilet and episodes of incontinence occur at various unscheduled times of the day, and so it is necessary for the patient to have a caregiver present throughout the day when help is needed with toileting related tasks. When the patient performs toileting tasks unassisted, there is greater risk of falls; and skin damage may occur from inadequate cleaning following toilet use and/or incontinence.

It is medically necessary for the patient to have caregiver assistance to properly and safely complete all daily activities throughout the day. Assistance is necessary to help prevent falls/injury (during mobility related activities); ensure adequate assistance with food/fluids; help prevent toileting related adverse events (falls, skin damage); help prevent complications of hereditary spastic paraplegia (HSP), joint disorders, poor mobility (e.g. contractures, pressure ulcers). Assistance with mobility is also necessary to help the patient participate in activities of interest in and outside of his home.  

Considering the patient's medical history and functional status, and his need for assistance at various and multiple times throughout the day from morning until bedtime, CDPAS 7 hours per day does not appear to adequately meet the patient's daily care needs. It is medically necessary, and in the patient's best interest to have caregiver assistance for a more extended period of time each day. CDPAS 60 hours per week will provide more service time per day and allow for greater flexibility to accommodate ADLs and IADLs inside the home and, when needed, assistance outside the home.  

Based on the above, the insurer's denial must be overturned. 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 directed personal assistance services (CDPAS) 60 hours per week services is substantiated.