Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia with mood disturbance, glaucoma
Treatment: Consumer directed personal assistance service (CDPAS), home care / personal care HHC (home health care)- level 2 personal care services, per 15 minutes increase to 65 hours per week
The insurer denied coverage for Consumer directed personal assistance service (CDPAS), home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 65 hours per week. 
The denial is Reversed.

This is an adult male with chronic medical problems. He lives alone in a private residence, his daughter lives close-by and visits daily. The insurer increased his CDPAS (Consumer directed personal assistance service), home care / personal care HHC (home health care)- level 2 personal care services, per 15 minutes from 45 to 50 hours per week. The patient is seeking consumer directed personal assistance service (CDPAS), home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 65 hours per week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times."  The patient is reportedly total dependent for completing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility and eating. The patient is reportedly occasionally incontinent of bladder and continent of bowel.  

The patient's activities of daily living (ADL) status has reportedly declined and he has reportedly fallen on 3 occasions over the prior 90 days. However, his cognitive and functional status is much the same when compared to the UAS (Uniform Assessment System) report done previously. The letter from the patient's treating nurse practitioner describing his clinical condition and need for "assistance at all times" was reviewed. The associated treatment notes were not submitted for review. After reviewing the submitted documents the reviewer agrees, the patient's condition and functional deficits are at a level or unpredictable as to require the requested consumer directed personal assistance service (CDPAS), home care / personal care HHC (home health care)- level 2 personal care services, per 15 minutes increase to 65 hours per week.

Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided with the requested consumer directed personal assistance service (CDPAS), home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 65 hours per week.

From a physical medicine and rehabilitation perspective, the requested consumer directed personal assistance service (CDPAS), home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 65 hours per week is medically necessary. Based on the above, the insurer's denial must be reversed. 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 service (CDPAS), home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 65 hours per week services is substantiated.