Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied Directed Personal Assistance Service (CDPAS) at 70.5 hours a week. 
The denial is overturned. 

The patient is a female with a past medical history of congenital myotonic dystrophy, diabetes mellitus, coronary artery disease, hypertension, constipation, hyperlipidemia, and gastroesophageal reflux disease (GERD) who had been assigned 55 hours of Consumer Directed Personal Assistance Program (CDPAP) services per week which increased to 70.5 hours/week following assessment tool performed assessing the patient at total assistance for all activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. The patient's primary care physician (or provider) (PCP) provider filled out Department of Health (DOH) form 4359 stating the patient was unable to independently perform any IADLs or ADLs due to muscle weakness and lack of coordination and was affected by serious, progressive disease that would not get better. This form also stated the patient must have assistance in turning, positioning in bed, toileting, and all aspects with her care. In addition, the DOH 4359 stated the patient needed more help with eating and drinking in the past 6 months. The patient underwent another assessment again assessing the patient at total assistance with all ADLs and IADLs and notes from the assessment indicating the patient was transferred be a Hoyer lift and was completely dependent on others for bathing, personal hygiene, dressing upper/lower body, and toileting.
The insurer sent final adverse determination notice to reduce, suspend or stop services denying request to increase CDPAP services to 70.5 hours/week. 
The patient's PCP provided another letter noting the patient's diagnoses and that the patient requires assistance with all ADLs and IADLs and patient required 112 hours a week of personal care at a minimum. The PCP also noted the patient's condition had not improved. The PCP also went through the assessment with the patient's family noting the patient required insulin before meals, was essentially quadriplegic by virtue of congenital myoclonic dystrophy and this was an inherent flaw in the assessment as there is no other place to indicate the patient's level of functional disability as the nurse assessor stated the patient was not quadriplegic.
At issue is the medical necessity of Directed Personal Assistance Service (CDPAS) at 70.5 hours a week.

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

The requested health service/treatment of Directed Personal Assistance Service (CDPAS) at 70.5 hours a week is medically necessary for this patient.
The patient has documented total assistance care needs with all ADLs and IADLs. The patient's PCP documented medical necessity of increased CDPAP services but instead of increasing CDPAP services, the patient's hours were decreased by approximately 25 hours. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met with adaptive equipment and medical supplies alone. 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 70.5 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.
Therefore, the requested health service/treatment of Directed Personal Assistance Service (CDPAS) at 70.5 hours a week is medically necessary.