Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Heart Disease, Cognitive Impairment

Treatment: Consumer Directed Personal assistance services (CDPAS); 84 hours per week.

The insurer denied the consumer Directed Personal assistance services (CDPAS); 84 hours per week.

The denial was overturned.


This is a male patient with a medical history of normal pressure hydrocephalus, narcolepsy, coronary heart disease with angina, cardiac pacemaker, hyperlipidemia, hypertension, gastroesophageal reflux disease(GERD), major depressive disorder, mild cognitive impairment, malignant neoplasm prostate, spinal stenosis, constipation, muscle weakness, vitamin deficiency. His current medical condition has caused him substantial functional impairment and needs assistance with daily activities. He lives alone, and was receiving Consumer Directed Personal Assistance Services (CDPAS) 25 hours per week. Following hospitalization and rehabilitation, the patient returned home and his daughter requested increase of CDPAS to 84 hours per week. 

It was reported that the patient is physically debilitated; appetite fair; lost weight. He needs assistance with ambulation and transfers; has had recurrent falls and is incontinent. Patient developed a pressure sore on the buttock. HHA is only 5 hours; daughter unable to take care of him; he needs 24 hours. He had a magnetic resonance imaging (MRI) of the brain in early this year that showed findings consistent with acute infarction basal ganglia; ventriculomegaly on age-related parenchymal volume loss, which may reflect NPH.

The UAS from early this year indicated the patient needed extensive assistance with bathing, lower body dressing and toilet use, and limited assistance for most other ADLs, including walking/locomotion. The patient was dependent on caregivers for all household related tasks (meal preparation, cleaning, shopping).

In addition to incontinence care, pressure relief is a necessary part of the patient's care plan for pressure ulcer prevention; and if pressure ulcer is present, for treatment. The patient needs turning and repositioning on a regular basis when he is in bed; and also if he is sitting in a chair for extended hours during the day. Pressure ulcers are a source of pain and can result in infection/sepsis and possibly surgical intervention. 

Another problem which was mentioned by the daughter is the patient's need for assistance with eating at all meals. He has difficulty with hand dexterity due to tremors, and he has cognitive impairment; both problems can decrease his ability to eat sufficient amount when alone. When he has pain, his appetite may decline, also causing decreased intake. Based on the UAS, the patient's BMI is 17.9 (underweight) which is comparable to the BMI (18.0) from the height/weight in the physician's order form for CDPAS. Frail elderly people who live alone are at risk for malnutrition and dehydration. It appears the patient had already lost weight. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Consumer Directed Personal Assistance Services (CDPAS); 84 hours per week is substantiated.  The insurer's denial is overturned.