Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg Pain 

Treatment: Initial Consumer Directed Personal Assist Services (CDPAS)
 
The insurer denied the initial consumer directed personal assist services (CDPAS).

The denial was overturned.

This is a patient with a history of type 2 diabetes (DM) and coronary artery disease (CAD) status post (s/p) stents, pain in left leg, chronic pain, and h/o falls. The patient fell in early 2020; causing injury to her left thigh. The patient's functional status; for IADLs, it is noted in the UAS that the patient needs extensive assistance for housework, and limited assistance for meal preparation, shopping and transportation. For ADLs, it is noted that patient is independent but needs setup help with bathing, hygiene, dressing, eating.  
This patient lives at home with her husband. The husband receives CDPAS 42 hours per week. The patient requested CDPAS (initial request for services).

It appears the patient's need for assistance is primarily for IADLs; with setup help for some personal care ADLs. The patient reports leg pain which is consistent with the patient's need for assistance with daily tasks that require the most physical work including standing and walking. Lower extremity pain is associated with decreased functional capacity. The nurse who performed the UAS developed a plan of care for the patient as noted in the UAS-ATSP Summary of Hours Recommended, which allocates time for IADLs 3 days per week. This is reasonable, as most of these IADLs do not necessarily need to be done every day. However, meals are needed every day, so additional time can be allocated for meal preparation daily.  The patient needs setup help with some personal care ADLs, and so a few minutes per day can be allocated for these tasks. The husband receives CDPAS. The details of his plan of care are not available for this review; and so there may be some overlap of household tasks between the patient's plan of care and the husband's plan of care (e.g. cleaning of common areas of the home). 

The number of CDPAS hours recommended for approval will be based on the UAS nurse assessor's recommendation (6.67 hours per week) plus additional time for daily meal preparation (7 days instead of 3 days per week) and some additional time for setup help with personal care ADLs (as indicated in the UAS). The total task hours recommended by the UAS nurse was 6.67 hours per week. Additional meal preparation time will be added for the additional 4 days per week based on the meal preparation time allocated per meal in the ATSP for Monday, Wednesday and Friday (breakfast 10 minutes; lunch, dinner 15 minutes); plus an additional 35 minutes per week (5 minutes per day) for set up help with personal care ADLs (bathing, dressing, personal hygiene). Total time will add up to 9.92 hours per week.

Although there is limited medical information in the available records, the UAS indicates the patient has some functional limitations with daily activities. The patient has medical conditions (diabetes mellitus, cardiac disease) that may contribute to the reported symptoms of pain and limited endurance for daily activities. Providing CDPAS can help relieve some of the difficulty the patient has with performance of daily activities. Based on her functional needs identified in the UAS, it appears the patient could benefit from CDPAS.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for initial consumer directed personal assist services (CDPAS) is substantiated. The insurer's denial is overturned.