Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Home Health Care

Diagnosis: Parkinson's disease
Treatment: Consumer Directed Personal Assistance Program 
The insurer denied Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week. The health plan's determination is overturned.

The patient is a male with past medical history of progressive supranuclear ophthalmoplegia with vision loss, Parkinson's disease, cerebrovascular accident (CVA), diabetes mellitus type 2 with neuropathy, hypertension, benign prostatic hyperplasia (BPH) with urinary retention, dizziness, unstable gait, vascular dementia, depression, anxiety, and urinary incontinence who had CDPAP (Consumer Directed Personal Assistance Program) services 6.5 hours/day, 7 days/week to total 45.5 hours/week based on assessment tool, the patient was assessed at total assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, phone use, stairs, transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, toilet use, bed mobility, and eating. Notes stated that the patient had minimally impaired cognition and walking was not tested because the patient did not walk on his own. There was a request to increase CDPAP services and the patient underwent a telephonic assessment assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, stairs, shopping, and dressing lower body. The patient was assessed at extensive assistance with tasks of phone use, transportation, dressing upper body, walking, locomotion, transfer toilet, and toilet use while limited assistance with tasks of personal hygiene, bed mobility, and eating.

Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 days a week; 12 hours per day - 7 days a week (split shift) - a total of 168 hours per week is medically necessary for this patient.
The patient has progressive diagnoses of Parkinson's disease and dementia with a documented decline in cognitive and physical functioning. The patient requires at least limited assistance with all activities of daily living (ADL)/Instrumental activities of daily living (IADL). The patient's providers documented the need with help turning position at night every two hours to prevent pressure ulcers with needed assistance to do so. The patient has 24 hour care needs and the plan inappropriately utilized the assessment tool to calculate CDPAP service hours. The patient has unscheduled and unpredictable care needs that span a continuum of time. The insurer did not document a plan to meet the assistance needs for the patient's unscheduled and unpredictable care needs. The plan assumed the patient's informal helpers were able to provide care continuously outside of the time the patient's CDPAP aide was available. Camera installment and monitoring does not replace assistance provided by CDPAP aide. The requested increase in CDPAP services hours are not solely for supervision and safety but to assist the patient with safe completion of ADLs/IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 12 hours/day, split-shift 7days/week, to total 168 hours/week 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 his own home.