Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Above knee amputation, GI Bleed.
Treatment:  Consumer and self-directed personal assistance services, 24 hours a week.
The insurer denied Consumer and self-directed personal assistance services, 24 hours a week.
The determination is overturned.

The patient has a past medical history of a right leg above-the-knee amputation, peripheral artery disease, diverticulitis with recurrent gastrointestinal (GI) bleeding, progressive systemic sclerosis, scleroderma, bowel incontinence, bladder incontinence, osteoarthritis, hypocalcemia, anxiety, depression, hypothyroidism, diabetes mellitus type 2, history of deep vein thrombosis (DVT), and chronic constipation who had been hospitalized with lower GI bleeding.
The patient was assigned 16 hours/week of Consumer Directed Personal Assistance Program (CDPAP) services and 8 hours of personal care assistant (PCA) service/day, 5 days/week, to total 40 hours/week based on a telephonic assessment tool performed assessing the patient at total assistance with tasks of ordinary housework and locomotion while maximum assistance with tasks of meal preparation, stairs, shopping, bathing, walking, transfer toilet, toilet use, and bed mobility. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, transportation, equipment management, and dressing lower body while limited assistance with tasks of phone use, personal hygiene, and dressing upper body. With the task of eating the patient was assessed as independent. The patient's rheumatologist provided a letter stating the patient has the condition of scleroderma which is a chronic condition that caused limited function of the hands and arms, was wheelchair bound due to right leg amputation and needed around the clock care to assist with activities of daily living (ADLs). The patient was hospitalized with lower GI bleeding.
There was a request to increase CDPAP services and the patient underwent an in person assessment assessing the patient at total assistance with tasks of ordinary housework, locomotion, and toilet use while maximum assistance with task of meal preparation, shopping, transportation, bathing, and dressing lower body. With the tasks of managing finances, personal hygiene, and dressing upper body the patient was assessed at extensive assistance while limited assistance with tasks of managing medication, bed mobility, and eating. The patient was assessed at set up only for phone use and it was noted activities did not occur during the assessment for tasks of equipment management, walking, and transfer toilet. Notes from the assessment noted the patient was wheelchair-bound and a Hoyer lift was used for transfers.
The patient was hospitalized again with lower GI bleeding. The insurer sent an initial adverse determination denial notice denying request to increase the CDPAP services. The insurer provided a final adverse determination denial notice denying the request to increase CDPAP services stating the plan recommended wearing easily removable clothing to help with toileting, recommended a commode to help with toileting, and the level of service allowed for the aide was sufficient to meet the patient's morning and evening needs. The denial stated the plan did not provide time for companionship, safety supervision, or when no tasks were being done. The patient was again hospitalized for lower GI bleeding.
The patient's health care advocate provided a request for external appeal of denial of requested increase in CDPAP services. The healthcare advocate letter also stated the patient received CDPAP services 16 hours/week on the weekends by the patient's grandson's wife. In addition, the letter stated the patient was previously able to rely on a live-in caregiver, her granddaughter, however the granddaughter gave birth and would shortly be returning to full-time work and was therefore no longer available to assist in the patient's care.
At issue is the medical necessity of consumer and self-directed personal assistance services, 24 hours a week. 
The services are medically necessary.
The patient's medical provider has documented the need for increased home care hours. The patient no longer has informal support from her granddaughter. The patient has had worsening physical functioning related to multiple hospitalizations for lower GI bleeding as well as a recent above-the-knee amputation. The patient requires at least maximum assistance with walking, locomotion, transfer toilet, and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of instrumental activities of daily living (IADLs) and ADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 24 hours/week are medically necessary for this patient. 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.