Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease with confusion and disorientation, behavioral problems, cognitive impairment
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day - 7 days per week - for a total of 56 hours per week
The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day - 7 days per week - for a total of 56 hours per week
The denial is overturned

This case involves a female diagnosed with Alzheimer's disease with confusion and disorientation, behavioral problems, cognitive impairment, who also suffered a cerebrovascular accident with right dominant side hemiparesis, muscle weakness, limited mobility, and had pain and stiffness related to osteoarthritis. She was being recommended for consumer directed personal assistance program (CD PAP) 8 hours a day, 7 days/week for total of 56 hours/week.

Functionally, she was totally dependent on others for meal preparation, ordinary housework, managing finances, managing medications, and shopping. She required set up only for telephone use. The document noted that the patient required extensive assistance with bathing, personal hygiene, dressing the upper and lower body, with limited assistance required for walking, locomotion, transferring, and toilet use. She was independent for bed mobility (set up only) and eating (set up only). Her primary mode of locomotion indoors included walking with an assistive device. She had no reported falls but did exhibit daily dizziness and an unsteady gait within the 3 days of the assessment. The patient reported occasional bladder incontinence with one occurring in the past 3 days of the assessment. This review pertains to the Denial of coverage for Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day - 7 days per week - for a total of 56 hours per week.

The Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day - 7 days per week - for a total of 56 hours per week is considered medically necessary for this patient.

Literature notes that Consumer-Directed Personal Assistance Programs provide an alternative way of receiving home care services in which consumers have more control over who provides their care and how it is provided. The information provided for the review noted that while the average determination report indicated that the patient was able to complete most tasks unassisted, the assessment conducted stated that the patient was totally dependent on others for meal preparation, ordinary housework, managing finances, managing medications, and shopping. She was also a potential fall risk given her prior CVA (cerebrovascular accident) and reports of daily dizziness and an unsteady gait. While she required limited assistance for walking, locomotion, transferring, and toilet use, given her cognitive decline and other physical limitations, it was determined that the requested services were supported. The prior determination is overturned.

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 Consumer Directed Personal Assistance Program (CDPAP): 8 hours per day - 7 days per week - for a total of 56 hours per week is overturned. Medical Necessity is substantiated.