Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cerebrovascular accident (CVA), Dementia.
Treatment:  Increase in Consumer Directed Personal Care assistance services from 56 hour per week to 70.

The insurer denied an increase in Consumer Directed Personal Care assistance services from 56 hour per week to 70.  The determination is overturned.

The patient has a past medical history of hypertension, hyperlipidemia, benign positional vertigo, dementia, depression, peptic ulcer disease, abnormal gait, osteoporosis, osteoarthritis, hearing loss, paroxysmal atrial fibrillation, peptic ulcer disease, ischemic stroke, bladder incontinence, and bowel incontinence who had been assigned Consumer Directed Personal Assistance Services (CDPAS) services 26 hours/week and personal care assistant (PCA) level II services 30 hours/week, to total 56 hours/week based on an assessment tool. The assessment tool assessed the patient at total assistance with the task of ordinary housework and maximal assistance with the tasks of meal preparation, stairs, and shopping. The patient was assessed at extensive assistance with the tasks of managing finances, managing medication, phone use, transportation, equipment management, bathing, dressing lower body, transfer toilet, and toilet use while limited assistance with tasks of personal hygiene, dressing upper body, walking, and locomotion. With the task of eating, the patient was assessed as being independent.
The patient had a telemedicine visit with her primary care physician (or provider) (PCP) noting a recent acute cerebrovascular accident (CVA) with weakness, significant change in mental status, and inability to ambulate without the assistance of two people. The patient was hospitalized with aspiration pneumonia. The patient had another telemedicine visit noting worsening dementia and depression and the start of hospice services. There was a request for an increase in services and the patient underwent another assessment tool over the telephone  assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, equipment management, and locomotion and maximal assistance with tasks of managing medication, phone use, bathing, personal hygiene, dressing lower/upper body, and toilet use. The notes from the assessment documented the patient had moderately impaired cognition, had a decline in activities of daily living (ADL) status since the prior assessment, had deterioration in overall self sufficiency since last assessment, daughter administers all of patient's medications, has been bed bound for the last four months, and needs to be fed. The health plan sent a final adverse denial determination notice stating the requested increase in CDPAS services was not medically necessary. The denial letter stated the request for increase was post hospitalization and her needs may be met with skilled home care services. In addition, the denial letter stated the patient's personal care tasks can still be done in the time that has been provided during the current hours you receive within your plan of care. The plan's denial also stated PCA services are not for safety supervision alone and the patient may call her care manager for help in arranging home health aide services through her hospice agency. The patient's PCP appealed the denial decision. At issue is the medical necessity of an increase in Consumer Directed Personal Care assistance services from 56 hour per week to 70 hours per week.

The requested services are medically necessary. The patient had a new medical diagnosis of CVA with change in functional status. Since her CVA, the patient was unable to feed herself, administer her own medication, and was bed bound with urinary and bowel incontinence. Furthermore, the patient's assessment tool showed an increase in the need for assistance with all tasks except ordinary housework (remained at total) from the one assessment to the next assessment. In addition, the later assessment underestimated the patient's assistance needs with tasks of managing medication (daughter administers all medication) and eating (patient needs to be fed). The plan incorrectly noted the patient's care needs changed during her hospitalization but had been present prior to this hospitalization as documented in the office notes following her CVA. The patient has unscheduled and unpredictable care needs for which the insurer did not document a plan of care. The patient has urinary and bowel incontinence and her care needs are not able to be scheduled. The increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ Consumer Directed Personal Assistance Services (CDPAS). 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, CDPAS/PCA services 10 hours/day, 7 days/week, to total 70 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.