Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia and hypercapnia
 
Treatment: 48 hours per week of consumer directed personal assistance services (CDPAS)

The insurer denied coverage for 48 hours per week of consumer directed personal assistance services (CDPAS). The denial reversed.

This patient is a female with advanced COPD, status post recent hospitalization for respiratory failure who lives alone with support from CDPAS and some informal help from family. She had been receiving CDPAS 48 hours per week until recently when CDPAS hours were reduced to 30 per week. The explanation by the insurer is that the patient's functional needs can be supported by 12 hours per week (as per recent assessment), and the previous approvals for 48 hours per week were done in error. In order to safely transition to less hours, CDPAS 30 hours per week were approved. 

The patient's Pulmonologist provided office visit notes from the past 2 years. It is evident that the patient has advanced COPD. She is oxygen dependent; uses BiPAP at night; multiple medications (bronchodilators, steroids); hospitalizations for exacerbation of COPD and respiratory failure. She also has congestive heart failure (treatment: torsemide, spironolactone), which can exacerbate her respiratory symptoms. The UAS indicates that the patient needs little or no assistance for most ADLs; however, it is necessary to consider the consequences of chronic respiratory disease in order to put the patient's functional status in perspective. Additional information in the UAS provides greater understanding of the patient's daily care needs.

Using the toilet can also be a stressful activity, requiring various maneuvers (walking to bathroom or commode; transferring on and off, cleaning/hygiene). The UAS reports the patient is independent with toileting, but it is a concern that she fell in the bathroom.  The details are not known, but several possible situations would be difficult for her to manage, e.g. if the floor was wet, she does not have the capacity to properly wipe it dry (she is totally dependent for housekeeping tasks); the work of getting on and off the toilet may cause her to lose balance and fall; the size of the bathroom may not allow for use of her walker, and so she may have limited support. Another concern about the recent fall is that she forgot to use the PERS. Such a mental lapse could happen again, and so the safety of her performing daily activities when alone is an even greater risk.

As per the information provided for review, the patient has advanced COPD, heart failure, status post multiple hospital admissions for COPD/respiratory failure, oxygen and BiPAP dependent, dyspnea at rest, severe fatigue, and very limited exercise tolerance. Therefore, it is medically necessary and in the patient's best interest to continue the amount of CDPAS services she has been receiving, i.e. 48 hours per week, which provides assistance during the hours of the day the patient is most active. The patient lives alone and has two informal helpers (as noted in the UAS), but both were noted as providing assistance for only IADLs; not ADLs. Without informal caregivers who can provide the assistance the patient needs for ADLs, then personal care services, in this case CDPAS, is medically necessary.

Consumer directed personal assistance services 48 hours per week is approved. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

The carrier's denial of coverage for 48 hours per week of consumer directed personal assistance services (CDPAS) is reversed. The medical necessity is substantiated.