Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer, osteoporosis, chronic obstructive pulmonary disease (COPD), and gastroesophageal reflux disease (GERD).
Treatment: Consumer directed personal assistant program (CDPAP) 14 hours per day, 7 days per week for a total of 98 hours per week.
The insurer denied coverage for CDPAP 14 hours per day, 7 days per week for a total of 98 hours per week.
The denial is overturned.

This patient has experienced functional decline associated with several health problems and needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She lives alone. She receives personal care services through CDPAP. The patient was receiving CDPAP 40 hours per week. The patient reported that due to her declining health, she needs more help. Request was made to increase CDPAP services to 98 hours per week, which was denied; but services were increased to 49 hours per week. External appeal was requested. 

The most recent Uniform Assessment System (UAS) provided was reviewed. The functional status report for IADLs indicated patient was totally dependent for ordinary housework, meal preparation, shopping; she needed maximal assistance for transportation; extensive assistance for managing medications and finances, stairs, equipment management; independent for phone use. For ADLs, the patient was totally dependent for bathing, dressing lower body, personal hygiene, walking, locomotion, transfer toilet, toilet use; she needed maximal assistance for dressing upper body; supervision for bed mobility, eating.

The patient has experienced significant adversity due to her medical conditions. Care plan goals should include prevention of new avoidable problems. There are few, if any, interventions that can prevent all falls, but when a person is identified as high risk for falls, it is necessary to implement a plan to help decrease occurrence of falls. The patient's comments in the external appeal application noted she was receiving physical therapy (no records are available), and this may provide some benefit; however, she still reported the need for more help.  She reported feeling exhausted/drained of energy, and so she may not achieve full benefit from rehab if her ability to participate is limited. 

Managed Long-Term Care (MLTC) policy 16.07 states that managed long term care plans must assure that the plan of care can meet any of the patient's unscheduled or recurring daytime or nighttime needs for assistance. Therefore, the patient's need for assistance with transfers, walking, toileting, meals that occurs at various unscheduled and/or recurring times during the day must be considered in the determination of the patient's personal care service hours. The information provided for review indicates the patient needs substantial assistance for various activities throughout the day. Therefore, it is medically necessary to have a caregiver present for daytime to evening hours to ensure the patient can safely and effectively perform all daily ADLs and IADLs; and help relieve some of the physical and mental stress associated with performing daily activities when experiencing pain, weakness, fatigue, dyspnea.

The patient's care needs occur throughout the day for IADLs and ADLs, including meal preparation; household tasks; morning and evening ADLs; plus ADLs that can occur at unscheduled, recurring times of the day, including toileting, mobility around the home, service/assistance with all meals. CDPAP is currently approved for 49 hours per week. It is unrealistic to expect 7 hours of CDPAP service per day to extend from morning until evening when the patient goes to bed. 

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 assistant program (CDPAP) 14 hours per day, 7 days per week for a total of 98 hours per week is overturned. Medical Necessity is substantiated.