Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease, Depression

Treatment: Consumer Directed Personal Assistance Program (CDPAP), 5 hours per day, 7 days per week, total of 35 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP), 5 hours per day, 7 days per week, total of 35 hours per week.

The denial is upheld. 

This is a patient with chronic medical problems including coronary artery disease, diabetes and depression.  The patient lives with their son, daughter-in-law and their infant child in a 3-bedroom home.  The insurer approved Consumer Directed personal Assistance Program (CDPAP) 3 hours/day, 4 days/week for a total of 12 hours/week. The request is for CDPAP, 5 hours/day, 7 days/week, for a total of 35 hours/week, leading to an external review.   

The Uniform Assessment System (UAS) report states that the patient's cognitive skills are described as "Modified independent."  The patient's ability to perform much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping reportedly varies from extensive to maximal assistance.   However, the patient is independent with Activities of Daily Living (ADL) tasks including bathing, personal hygiene, dressing, eating, bed mobility, locomotion, toilet transfer/use and ambulation.   The patient reports being frequently incontinent of bladder and continent of bowel.  The patient reportedly fell on 1 occasion over the prior 30 days.  The patient's functional ability is much the same when compared to the previous UAS report.

The patient's condition and functional deficits are not at a level or unpredictable as to require the requested CDPAP 35 hours/week.  The patient is independent with ADLs.  This physician would agree the patient may benefit from monitoring for safety, particularly due to the patient's reported cognitive status.  However, CDPAP for companion care or safety supervision without the direct provision of ADL task assistance is not a covered service.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the approved CDPAP 3 hours/day, 4 days/week for a total of 12 hours/week.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, CDPAP, 5 hours per day, 7 days per week, total of 35 hours per week is not medically necessary.   

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Assistance Program (CDPAP), 5 hours per day, 7 days per week, total of 35 hours per week is not substantiated.