Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis, Dementia.
Treatment:  Additional Consumer Directed Personal Assistance Services (CDPAS) hours weekly.

The insurer denied coverage for additional Consumer Directed Personal Assistance Services (CDPAS) hours weekly.  The denial is overturned.

This is a female patient with a medical history of dementia, atrial fibrillation (on anticoagulation), coronary artery disease, pulmonary embolism, obstructive sleep apnea, cognitive impairment and recent weight loss.  The patient has been receiving Consumer Directed Personal Assistance Services (CDPAS).  She is currently approved for CDPAS at 59 hours per week.  Additional CDPAS hours were requested but did not specify the number of hours.  The request for an increase of hours was denied.

The patient has several chronic medical conditions and substantial functional impairment.  She lives in a house with her daughter.  The patient's medical history includes several medical conditions that most likely have significant adverse effect on the patient's physical ability to perform daily activities including osteoarthritis, asthma, and weight loss.  The functional assessment from the most recent Uniform Assessment System (UAS) report indicated that the patient was totally dependent for all household tasks, shopping and finances; needs maximal assistance for medications, stairs and transportation; extensive assistance for phone use.  For activities of daily living (ADLs), the patient needs maximal assistance for all ADLs except bed mobility, upper body dressing (extensive assistance) and eating (limited assistance).  The patient has dementia with some behavioral issues (e.g. paranoia, anger).  She also has difficulty sleeping at night.

It is apparent that the patient needs caregiver assistance for all daily activities.  With current CDPAS hours (59 per week) this averages approximately 8.5 hours per day.  Currently, it is noted the daughter and her husband provide all other care when the aide is not present, which extends beyond 8.5 hours per day.  The patient appears to be at a stage of physical and cognitive impairment that requires a caregiver for various types of assistance throughout the day and most likely during evening and night hours.  The UAS indicates the patient's daughter and son-in-law are the primary informal caregivers for the patient.  It does not appear there are any other informal caregivers.  The patient had one other source of formal services.  She was attending a social day care program 15 hours per week until it closed.  It appears that the level and frequency of care needed to maintain the patient's health and safety cannot be met with CDPAS 59 hours per week.  The patient's cognitive status is severely impaired, and she needs assistance for all ADLs.  It is medically necessary for the patient to have a caregiver present to provide assistance with all ADLs when needed throughout the day and night to ensure proper completion of daily tasks and to help prevent adverse health and safety events, such as falls/injuries, skin damage (from incontinence and/or pressure), and nutritional decline.

The services that can be approved from this review are limited by the request.  In this case, because the request was for an increase in CDPAS hours with no specific number of hours requested, this reviewer can recommend that additional hours are indicated, but cannot recommend a specific number of hours. 

The healthcare plan did not act reasonably with sound medical judgement, and in the best interest of the patient.

The carrier's denial of coverage for the requested additional CDPAS hours weekly is overturned.  The medical necessity is substantiated.