Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis.
Treatment: Consumer directed personal assistance, a total of 30 hours per week.
The insurer denied Consumer directed personal assistance, a total of 30 hours per week.
The determination is overturned.

This is a female patient with a past medical history of osteoarthritis, osteoporosis, low back pain, sciatica, lower extremity edema, and urinary incontinence who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 20 hours/week. There was a request to increase the CDPAP services and the patient underwent an assessment assessing the patient at total assistance with the tasks of ordinary housework while maximum assistance with the tasks of meal preparation and shopping. With tasks of managing finances, stairs, transportation, equipment management, bathing, dressing upper/lower body, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of managing medication, personal hygiene, walking, and locomotion. The patient was assessed at set up help only with phone use and independent with bed mobility and eating. Notes from the assessment stated the patient requested more assistance with dressing and bathing, had a decline in activities of daily living (ADL) status in the last 90 days, had a deterioration in overall self-sufficiency in the last 90 days, lived alone, and had no informal helper. A tasking tool estimated 21.27 hours/week. The assessment notes also stated the patient was observed with a poor gait using a high rollator with personal care assistant (PCA) provided guided support. In addition, the patient stated due to a fear of falls, unless her children visit, she does not eat until her PCA returns the next day. The insurer sent a final adverse determination denial notice denying the request to increase CDPAP services stating the hours provided under her last authorization or reauthorization were still enough to meet the patient's needs. The plan also recommended speaking with her Consumer Directed Personal Caregiver regarding a schedule that would better fit the patient's care needs. At issue is the medical necessity of consumer directed personal assistance, a total of 30 hours per week.
The services are medically necessary. There is documentation from the plan on assessment of assistance needs with all tasks except for bed mobility and eating. The patient requires at least extensive assistance with transfer toilet and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The plan recommended scheduling CDPAP service hours to better meet her care needs, however, as above, the patient has unpredictable and unscheduled care needs. The patient has no informal help. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 30 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.