Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia, pre-diabetes, acquired hypothyroidism, lumbar spinal cord injury, iron deficiency anemia, cataracts, arthritis.
Treatment: Consumer directed personal assistance services (CDPAS) of 10 hours per day, 7 days per week for a total of 70 hours per week.

The insurer denied coverage for consumer directed personal assistance services of 10 hours per day, 7 days per week for a total of 70 hours per week.  The denial is overturned.

This female has functional impairment associated with various medical conditions and needs assistance with most daily activities. The patient lives alone and has no informal helpers. She receives Consumer Directed Personal Assistance Services (CDPAS) 8 hours per day, 7 days per week; 56 hours per week. The patient requested increase of services to 10 hours per day, 7 days per week; 70 hours per week, which was denied. External appeal was requested. 

A Uniform Assessment System (UAS) was done. For instrumental activities of daily living (IADLs), the patient needs maximal assistance for household related tasks (meal preparation, housework) and shopping; extensive assistance for stairs and transportation; limited assistance or setup help with finances, medications, phone use. For activities of daily living (ADLs), she needs extensive assistance with bathing, lower body dressing; limited assistance for other ADLs; except bed mobility, eating (setup help).

The patient has neurogenic bladder and urinary retention with an indwelling catheter. The patient also has history of (h/o) bowel dysfunction including constipation and bowel incontinence which also may be related to spinal cord injury. It is likely the patient needs assistance, as she has difficulty managing lower body change of clothes and bathing. Bowel incontinence needs to be managed as soon as possible for patient comfort, and to prevent prolonged skin exposure to wet soiled pullup or diaper, which can lead to incontinence associated skin damage (e.g. dermatitis, fungal infection).

The UAS reports the patient has difficulty with transfers, walking and prolonged standing. The pain in her lower back, knees and hips can affect ambulation and sit-to-stand transfers (chair, bed, toilet). Shoulder pain and decreased range of motion affects various daily activities including bathing, personal hygiene, upper body dressing, toileting; and household related tasks requiring reaching, lifting, carrying. Shoulder pain can also affect ambulation for a person dependent on using a walker. 

The patient needs assistance for daily activities that occur at scheduled and unscheduled times throughout the day. This includes all meals and routine household-related tasks; routine morning and evening ADLs; and unscheduled ADLs including transfers, walking, wheelchair mobility, toileting, incontinence care. Without adequate assistance, the patient is at risk for adverse health and safety events such as: injury due to falls/household accidents; skin damage due to inadequate incontinence care; risk of nutritional decline if patient skips meals when alone; risk of unsafe emptying procedure for urinary drainage bag. 

The patient needs assistance with ADLs and IADLs at various times from morning until evening. The request for increase of services is for 70 hours per week, 10 hours per day. Optimal CDPAS aide schedule can be determined with the patient. 

Consumer Directed Personal Assistance Services 10 hours per day, 7 days per week, total of 70 hours per week are medically necessary. 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 the requested Consumer Directed Personal Assistance services of 10 hours per day, 7 days per week for a total of 70 hours per week is overturned. Medical necessity is substantiated.