Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 

The insurer denied an increase in Consumer Directed Personal Assistance Services (CDPAS) from 42 hours to 70 hours per week. 
The denial is overturned. 

The patient is a male with a past medical history of coronary artery disease, atrial fibrillation, hypertension, hyperlipidemia, foot drop, venous insufficiency, benign prostatic hyperplasia (BPH), gastroesophageal reflux disease (GERD), urinary incontinence, major depressive disorder, obesity, and gout who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 42 hours/week based on telephonic assessment tool assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. With tasks of managing medication, stairs, transportation, bathing, and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of managing finances, personal hygiene, dressing upper body, walking, locomotion, and transfer to the toilet. The patient was assessed as independent with tasks of phone use, toilet use, bed mobility, and eating. There was a request to increase CDPAP services and the patient underwent another assessment assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was assessed at extensive assistance with tasks of stairs, transportation, bathing, and dressing lower body while limited assistance with tasks of managing finances, managing medication, personal hygiene, dressing upper body, walking, locomotion, transfer to the toilet, and toilet use. The patient was assessed at supervision with task of bed mobility, set up with task of phone use and independent with task of eating. Notes from the  assessment stated the patient had no informal helper.
At issue is the medical necessity of the increase in Consumer Directed Personal Assistance Services (CDPAS) from 42 hours to 70 hours per week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of increase in Consumer Directed Personal Assistance Services (CDPAS) from 42 hours to 70 hours per week is medically necessary for this patient.
The patient's medical provider documented worsening physical functioning related to his medical illnesses and medical necessity for increase in personal care assistance. The assessment noted the patient had a decline in activities of daily living (ADL) status and overall self-sufficiency in the last 90 days and the patient had no informal help. The patient required at least limited assistance with walking, locomotion, transfer to the toilet, and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled 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 (IADL)s. The patient's care needs cannot be met solely with medical supplies and adaptive equipment. 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 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 his own home.
Therefore, the requested health service/treatment of increase in Consumer Directed Personal Assistance Services (CDPAS) from 42 hours to 70 hours per week is medically necessary.