Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic back pain, hypertension and joint pain

Treatment: CDPAS (consumer directed personal assistance services) 24 hours a day (live-in)

The insurer denied coverage for CDPAS 24 hours a day (live-in)

The denial is upheld

This is an adult male with chronic back pain, hypertension and joint pain.   He lives alone in a private residence.  His daughter is the paid caregiver.  His family is supportive and involved with his care.  The insurer approved consumer directed personal assistance services (CDPAS) 42 hours per week (6 hours x 7 days).  The request is for CDPAS 24 hours a day (live-in); leading to an external review. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as modified independent.  He reportedly requires maximal assistance for completing much of his Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance with bathing, lower body dressing and toilet use.  Limited assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility, locomotion, toilet transfer and ambulation.  He is independent with eating.  The patient reports being frequently incontinent of bladder and infrequently incontinent of bowel.  There has been no reported change regarding his ability to perform activities of daily living and self-sufficiency over the prior 90 days.  There have also been no reported falls over the prior 90 days.  The patient's cognitive and functional ability are much the same when compared to the prior UAS report.  

Based on the documents submitted for review, the patient's medical condition and functional ability are not at a level or unpredictable as to require the requested CDPAS 24 hours a day (live-in).  The clinical treatment notes were reviewed.  Most of the treatment notes are from his primary physician (infectious disease specialist).  The patient was more recently seen.  He was described as "alert and oriented x 3, walking with a cane."  The patient was otherwise, "(in) no acute distress, well appearing, alert and oriented."  The clinical notes do not describe a level of functional incapacity to support the medical necessity of the requested CDPAS 24 hours/day (live-in).

This physician would agree the patient may benefit from additional monitoring for safety; particularly due to his reported weakness and falls risk.  However, personal assistance service ( (PAS) hours are approved primarily to provide hands-on assistance for completion of Instrumental activities of daily living (IADL)/activities of daily living (ADL) tasks when no else is available to provide assistance.   Based on the documentation submitted for review, the patient's health and safety are appropriately provided and maintained at home with the approve CDPAS 42 hours/week.   The patient also has the option of restructuring and flexibly using the 42 CDPAS hours weekly to better maintain and meet his functional needs.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for consumer directed personal assistance services (CDPAS) 24-hour live-in care is not substantiated.