Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase in Consumer Directed Personal Assistance Services (CDPAS) from 42 hours/week to 84 hours/week
The insurer denied the increase in CDPAS from 42 hours/week to 84 hours/week.
The determination is overturned.

The patient has a past medical history of dementia, urinary incontinence, bowel incontinence, chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidemia, benign prostatic hyperplasia (BPH), and hearing loss who had been assigned personal care assistant (PCA) services 42 hours/week based on an assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, phone use, stairs, and transportation. The patient was assessed at extensive assistance with the task of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility while supervision with the task of eating. Notes from the assessment stated the patient had a decline in activities of daily living (ADLs) status and deterioration in overall self sufficiency in the last 90 days. The tasking tool estimated 39.67 hours/week.

The patient was hospitalized with a traumatic subdural hematoma. There was a request to increase PCA services and the patient underwent another assessment assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, stairs, shopping, transportation, and locomotion while maximum assistance with tasks of bathing, dressing lower body, and walking. With the tasks of personal hygiene, dressing upper body, transfer toilet, and toilet use. The patient was assessed at limited assistance with task of eating and independent with task of bed mobility. Notes from the assessment stated the patient lived with her husband, had moderately impaired cognition, had a decline in ADLs status over the last 90 days, and deterioration in overall self sufficiency in the last 90 days. The tasking tool estimated 50.08 hours/week.

The insurer sent an initial adverse determination denial notice denying request to increase PCA services stating the services were not medically necessary. The insurer sent a final adverse determination denial notice continuing to deny request to increase PCA services. The denial stated the patient had no loss of motor function, the patient was reassessed and authorized hours were adjusted accordingly, and hours beyond those currently authorized would be for safety monitoring. The patient had an office visit with the PCP (primary care physician or provider) with office visit for follow up forgetfulness, abnormal high cholesterol, hypertension, urinary hesitance, and chronic bronchitis. The office note also stated the patient typically was up twice at night to use the bathroom. The patient and family appealed the denial decision. At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS) from 42 hours/week to 84 hours/week.

The services are medically necessary.

The patient requires at least extensive assistance with the tasks of walking, locomotion, transfer toilet, and toilet use. The patient has urinary and bowel incontinence. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested PCA services are not solely for safety and supervision but to assist the patient with ADLs/instrumental activities of daily living (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, PCA services 12 hours/day, 7 days/week, to total 84 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.