Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease, Dementia.
Treatment: Consumer Directed Personal Assistance Services (CDPAS): live-in- 24 hour, 7 days per week for total of 91 hours.
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): live-in- 24 hour, 7 days per week for total of 91 hours. 
The determination is overturned.

The patient has a past medical history of osteoporosis, hypertension, Parkinson's disease, transient ischemic attack (TIA) with resultant leg weakness, urinary incontinence, thoracic (T) 11-T12 fracture with severe chronic pain and spinal cord compression, dementia, and bedbound status who had been assigned consumer directed personal assistance program (CDPAP) services 7 hours/day, 5 days/week and 6 hours/day 2 days/week. The patient was hospitalized and there was a request to increase the CDPAP services and the patient underwent a video assessment. The patient was assessed at total assistance with the tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, and locomotion while maximum assistance with tasks of managing medication, phone use, transportation, bathing, dressing lower body, transfer toilet, and toilet use. With the tasks of personal hygiene, dressing upper body, bed mobility, and eating the patient was assessed at extensive assistance. Notes from the assessment stated the patient lived alone downstairs from her son and his family, she was bedbound, had a decline in activities of daily living (ADLs) status over the last 90 days, and had a deterioration of overall self-sufficiency in the last 90 days.

The insurer sent an initial adverse determination denial notice denying request to increase personal care services. The denial stated the plan found the patient required an adjustment in her current schedule and the nurse found the current hours could meet all of the tasks the patient needed help with today. It was recommended that hours be spread throughout the day to meet all of her needs. The plan recommended physical and occupational therapy as well as adaptive equipment to help with repositioning and incontinence care. Lastly, the plan stated overnight services would be for safety supervision which is not a covered service.
The plan sent a final adverse determination denial continuing to deny the requested increase in CDPAP services. Caregiver logs were provided noting care needs with ADLs approximately every 2-5 hours overnight. The patient's primary care physician (or provider) (PCP) provided a letter on behalf of her patient to document the medical necessity of an increase in home care hours. The provider outlined the patient's past medical history and patient was unable to conduct any care for herself in regards to activities of daily living and patient was incontinent and bed confined and needed assistance with nearly all activities including but not limited to self-care, ambulation, and transfers. The provider also noted the patient was at high risk for falls and the patient had been hospitalized with pleural effusion requiring drainage and her condition would not likely improve. Lastly, the provider stated the patient required 24 hours a day of total care and the family was currently paying out-of-pocket in order to provide the patient the care she needs and an in person evaluation to accurately assess the patient's current functional status was recommended to make a determination of the amount of hours the patient should receive. The patient's legal advocate provided a letter requesting external appeal of denial decision.

At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS): live-in- 24 hour, 7 days per week for total of 91 hours. 
Yes, the services are medically necessary. 

There is documentation of worsening cognitive and functional status with worsening dementia, recent hospitalization, and bedbound status. The patient requires assistance with all ADLs/ Instrumental activities of daily living (IADLs) including locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's functional status and cognitive status would not likely improve enough to become independent with unscheduled and unpredictable care needs with the recommended occupational or physical therapy. 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/day, live-in, 7 days/week, to total 91 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.