Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus, hypertension, thyroid disorder, gastroesophageal reflux disease, hyperlipidemia, mid-cervical disc disorder, osteoarthritis, abnormality of gait and mobility, glaucoma, hearing loss and falls.

Treatment: consumer directed personal assistance services (CDPAS) of 25 hours per week.

The insurer is denied coverage for consumer directed personal assistance services (CDPAS) of 25 hours per week.

The denial is overturned. 

This elderly female has functional impairment due to various medical conditions and needs some assistance with most activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient receives assistance through CDPAS (her son is CDPAS aide). The insurer's appeal decision notice states the same CDPAS hours from the previous authorization is enough to meet the patient's needs; but does not indicate the specific hours per week the patient is currently receiving. The Uniform Assessment System (UAS) indicates the patient receives CDPAS 15 hours per week but does not describe allocation of hours (number of hours per day; number of days per week). The UAS indicates the patient was receiving CDPAS 5 hours per day, 3 days per week. The patient's son (not the same son as CDPAS aide) requested increase of CDPAS to 25 hours per week. The patient's functional status report indicates the patient needs extensive assistance with most IADLs; except managing medications (limited assistance) and phone use (independent). The patient needs limited assistance for most ADLs; except personal hygiene and eating (setup help only).

The patient has multiple risk factors for falls including arthritis, unsteady gait, impaired balance, dizziness, advanced age, history of falls, cognitive decline/memory impairment.  When older people fall, there is increased risk of serious injury (e.g., fractures, head trauma) associated with substantial morbidity and increased risk of death. Few, if any, interventions can prevent all falls; but the purpose of fall assessment is to identify risk, and when necessary, develop a plan to decrease the occurrence of falls.  This is not stand-alone safety supervision. When a person needs help to safely move around the home, this is necessary ADL assistance (walking, transfer activity including toilet transfer). When older people with physical impairments live alone, they often have no choice but to attempt various daily tasks even if they do not feel secure about their ability to perform the activity. Caregiver assistance can provide stability, physical support (when needed), and safety cues for guidance for walking and transfers. These interventions to assist with mobility related tasks can be the difference between falling and safe mobility. It is reasonable to expect that it is less likely the patient will fall if she has a caregiver present to assist with mobility in the home. Transfers (including toilet) and walking occur at various unscheduled times of the day; and so, the patient needs a caregiver present at least during the patient's most active hours of the day. Assistance and supervision/cues for safety with ADLs is an important aspect of care provided by personal care aides. Caregiver assistance with mobility can help decrease the occurrence of falls.

Consumer Directed Personal Assistance Services 25 hours per week is medically necessary.

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 25 hours per week is overturned. Medical necessity is substantiated.