Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident (CVA)/stroke, heart failure, coronary artery disease (CAD), and cancer.

Treatment is an increase in consumer directed personal assistance program (CDPAP) services: 5.5 hours per day, 7 day(s) per week - for a total of 38.5 hours per week.

The insurer denied coverage for an increase in consumer directed personal assistance program (CDPAP) services: 5.5 hours per day, 7 day(s) per week - for a total of 38.5 hours per week.
 
The denial is overturned.

This elderly male has an extensive medical history associated with functional decline and lives alone. He needs help with most activities of daily living (ADLs) and relies on assistance from personal care services, provided through Consumer Directed Personal Assistance Program (CDPAP). The patient receives CDPAP services 31.5 hours per week (4.5 hours per day). He also receives some informal help from his family. The patient requested an increase of CDPAP services to 38.5 hours per week (5.5 hours per day), which was denied. 

The most recent UAS (uniform assessment system) provided for the review was done. The functional status report for IADLs (instrumental activities of daily living) indicates the patient is dependent on ordinary housework; he needs maximal assistance for meal preparation, shopping, and managing medications; extensive assistance for managing finances, and stairs; limited assistance for transportation; independent for phone use. For ADLs, the patient needs extensive assistance for bathing, personal hygiene, dressing the upper and lower body, transferring toilet; limited assistance for walking, and locomotion; set up help for bed mobility, toilet use, and eating.

The patient needs reminders for medications, and help with finances, which may be at least partly due to cognition. Based on the description of the patient's cognition in UAS, it is unlikely the patient's ADL function is affected by cognitive impairment (ADL function is usually not affected by a cognitive decline until later stages of impairment). However, memory loss may increase the risk of falls and household accidents during ADLs and household tasks, as the patient may not always remember safety precautions when performing various activities. Based on available information, it appears the patient's need for help with daily activities is mostly due to physical functional decline, but he also needs reminders/cues for some tasks.

Considering the patient's medical history and functional impairment, it is medically necessary for him to have assistance with daily activities when needed during the day, including meal preparation/service (and possibly with eating); routine ADLs (bathing, dressing, personal hygiene); mobility and toileting (which generally occur at unscheduled, recurring times of the day). MLTC (Managed Long-Term Care) policy 16.07 states that plans must assure the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. The patient needs help during the day for the proper and safe completion of ADLs and IADLs. These care needs must be considered in the determination of the patient's care service hours.

The recommendation is given to approve Consumer Directed Personal Assistance Program services, 5.5 hours per day, 7 days per week, a total of 38.5 hours per week. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the increase in consumer-directed personal assistance program (CDPAP) services: 5.5 hours per day, 7 days (s) per week - for a total of 38.5 hours per week is overturned. Medical Necessity is substantiated.