Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal - Osteoarthritis
Home Health Care 

The patient is a female with past medical history of rheumatoid arthritis and osteoarthritis with chronic pain and hand deformities. The patient also has significant past medical history of dementia, osteoporosis, hypertension, irritable bowel syndrome with fecal incontinence and urinary incontinence. The patient is on diuretic for treatment of hypertension. The patient is on Aricept for dementia. The patient had Consumer Directed Personal Assistance Program (CDPAP) services 12 hours per day/84 hours per week. The patient had an assessment tool done. The provider requested increase in services due to patient's worsening condition. There was a repeat assessment and patient remained at the same level of assistance from the prior assessment. Increase in services were denied. The provider wrote a letter following a home visit/house call reporting the patient needed 24 hour split shift CDPAP services 7 days a week. It was noted that the patient had worsening pain with arthritis, decreased functioning, worsened memory, frequent urination. Per overnight log the patient required assistance with transfer, turning, positioning, toileting and incontinence cares every 2-3 hours overnight. The patient has had falls with ambulation. The patient has had more difficulty with weight bearing due to severe pain in the left hip. The patient was noted to have falls mainly when she attempted to go unattended to the bathroom. The provider wrote another letter indicating the patient needed 24 hours care in split shifts/7 days per week. The patient was felt to be at high risk for falls. The patient was felt to have poor safety awareness. The patient took aspirin daily due to history of previous deep vein thrombosis (DVT) and there was concern for more severe injury in the setting of repeated falls. It was noted that the patient was having difficulty holding the walker properly due to deformity of hands related to arthritis. The patient was also noted to have difficulty holding spoon, cup and was unable to operate small objects. The subject under review is the medical necessity for the 24 hour split shift CDPAP services 7 days a week.

The health plan's determination is overturned.

The requested health service/treatment of increase in consumer directed personal care assistance services to 24 hours per day (split shift)/7 days a week to total 168 hours a week is medically necessary.
The patient has medical diagnoses that have worsened or progressed since her last assessment per medical records. The patient has multiple co-morbid conditions making it difficult for her to care for herself. Specifically, she has a history of rheumatoid and osteoarthritis with bilateral hand deformities and daily chronic pain in the lower extremities limiting her ability to ambulate, transfer, position, toilet and participate in incontinence cares. It was recommended by the insurer that the patient should do physical therapy (PT), however patient had underlying dementia which would limit the ability for the patient to recall/remember recommendations by physical therapy. The patient also has severe hand deformity making it difficult for her to grasp and maneuver her rollator walker. The patient's medical provider for over 5 years (who does home visits on the patient) recommended that the patient have 24 hour CDPAP services in split shifts, 7 days a week due to above and due to her high risk of falls (with previous recent falls) and her poor safety awareness. Furthermore, there is documentation supporting the overnight CDPAP services overnight due to her frequent need to urinate with history of diuretic use, urinary incontinence requiring incontinence care and occasional fecal incontinence requiring incontinence care. Even though the assessment tool done did not show significant changes from the previous assessment, the patient has documented falls when alone, difficulty with transferring, positioning, toilet use and incontinence cares, specifically in the evening and overnight hours. The patient lacks safety awareness and has fallen with attempts to go to the bathroom unattended and slid off the couch when unsupervised. CDPAP services are medically necessary to help this patient with nutritional and environmental support functions and personal care functions essential to the maintenance of the patient's health and safety in her own home.