Appeal type: Medical necessity
Decision: Overturned

Diagnosis: osteoarthritis, chronic knee pain, gait instability
 
Treatment: Increase in Consumer Directed Personal Assistance (CDPAS) 

The insurer denied coverage for increase in Consumer Directed Personal Assistance (CDPAS) from 25 hours per week to 50 hours per week. The denial is reversed. 

This patient is a female who lives at home with her son, daughter-in-law, grandchildren. It appears that another son who does not live with the patient is very involved as well. The patient has several medical conditions and significant functional impairment. The patient has been receiving CDPAS 5 hours per day, 5 days per week. The family is requesting increase to 50 hours per week. The insurer denied the request on final appeal. 
Patient's medical history was obtained from the physician's letter, physical therapy notes and the UAS. Several medical conditions most likely have a significant effect on the patient's functional impairment including the following: osteoarthritis, with pain and gait abnormality. The physician noted chronic knee pain and gait instability.

The most current available records are from physical therapy. It is noted that patient's primary complaints are bilateral knee and right shoulder pain. Pain description indicates patient has periods of significant pain (worst pain score for right knee 7, left knee 4, right shoulder 8). Description of specific problems included pain, limitation walking, difficulty changing positions, knee tenderness, decreased muscle strength, decreased ROM, limitation with carrying, handling objects. These problems have substantial negative effect on the ability to perform daily activities, and explain the patient's need for extensive (weight-bearing) assistance with most ADLs.

The patient has substantial functional needs regarding toileting and incontinence: UAS reports frequent urinary incontinence and occasional bowel incontinence. The causes are not identified in the records; however, one contributing factor may be due to difficulty getting to the bathroom (i.e. functional incontinence). The patient walks slowly and needs assistance; and even if assistance is available, she may not get to the toilet in time. The patient needs extensive assistance for toileting, dressing, and bathing/hygiene; and so it is likely she needs assistance for incontinence care, i.e. changing pads, proper hygiene after each episode, possibly changing clothes. If the patient does not have prompt assistance for incontinence, she is at risk for incontinence associated skin injury (e.g. dermatitis, fungal infection). Comparison of the two UAS reports indicates the level of assistance for toilet transfer and toilet use increased from limited assistance to extensive (weight-bearing) assistance. The need to use the toilet and episodes of incontinence are unpredictable and occur throughout the day. Without assistance, the patient cannot properly and safely use the toilet or provide timely and adequate incontinence care.

In elderly people with multiple medical problems, functional decline is often due to combined effects of various physical and mental signs/symptoms. The records provided for review support the patient's need for assistance with IADLs and ADLs due to physical and cognitive impairment. The patient requires extensive assistance for ADLs that occur unscheduled, throughout the day (transfers, walking, toileting, incontinence care). The current number of CDPAS hours (5 hours per day, 5 days per week) is not sufficient for the patient's daily care needs.

Recommendation is given to approve Consumer Directed Personal Assistance Services (CDPAS) 50 hours per week. 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 an increase in Consumer Directed Personal Assistance (CDPAS) from 25 hours per week to 50 hours per week is substantiated.  The insurer's denial is reversed.