Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Gastroesophageal Reflux Disease (GERD)
Treatment: Consumer Directed Personal Assistance Services
The health plan denied the requested Consumer Directed Personal Assistance Services as not medically necessary.
The health plan's determination is overturned.

The patient is a female with a past medical history of schizoaffective disorder, conversion disorder with seizure, urinary incontinence, gastroesophageal reflux disease (GERD), asthma, bilateral sciatica and post-traumatic stress disorder (PTSD) who requested Consumer Directed Personal Assistance Services (CDPAS) services and underwent an assessment via video.

The outcome of the assessment included the patient requiring extensive assistance with the task of ordinary housework and supervision with the task of managing finances. The patient was assessed at independent with all other tasks. Notes from the assessment documented the patient stating they need help with bathing and using the toilet because they have trouble with these tasks after seizures. Also, the patient stated she needs help with cooking, cleaning, and standing because her bilateral sciatica makes it very difficult. Furthermore, the patient also reported her mother had been providing care 14 hours per week through home health care. Notes from the assessment also stated the patient's overall self-sufficiency had deteriorated in the last 90 days.
The patient's psychiatric social worker provided a letter requesting consideration for home health services, stating due to the patient's mental health and physical health disabilities the patient has trouble taking care of activities of daily living (ADL) such as cooking, cleaning, bathing herself, and grooming. The letter also stated the patient needed support with scheduling medical appointments, as well as having someone physically accompany her to appointments.

In addition, the letter stated that due to the patient's psychogenic nonepileptic seizures, these tasks can be challenging to complete. Lastly, the letter stated the patient required prompting and cues to remember day-to-day tasks and activities as well as relaying important medical information to their healthcare providers. 

At issue is the medical necessity of Consumer Directed Personal Assistance Services. The health plan's determination of medical necessity is overturned, in whole. The requested health service/treatment of Consumer Directed Personal Assistance Services is medically necessary for this patient.

There is documentation from the patient's psychiatric social worker of need of assistance with specific tasks, including cooking, cleaning, bathing, and grooming, as well as transportation and scheduling of medical appointments. The patient has psychogenic nonepileptic seizures unpredictably with further increased assistance needs during these times. The patient had been receiving 14 hours per week of services in the past. The video assessment underestimated the patient's assistance needs with tasks of meal preparation, ordinary housework, medication management transportation, bathing, and personal hygiene, and therefore, qualifies for Consumer Directed Personal Assistance Services (CDPAS).

The patient's primary care physician (or provider) (PCP) appealed the denial decision by the insurer. The patient's own mental health diagnoses are questionable at any of the video assessment and obtaining an accurate assessment of the patient's activities of daily living and instrumental activities of daily living (IADL) needs. Taking into account information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Consumer Directed Personal Assistance Services 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 their own home.