Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic pain
Treatment: consumer directed personal assistance service (CDPAS) 46 hours per week (plan reduced to to 17 hours per week). 
The insurer denied the consumer directed personal assistance service (CDPAS) at 46 hours per week (plan reduced to to 17 hours per week). The health plan determination is overturned.

The patient is a female with a past medical history of diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidemia, neuropathy, osteoporosis, osteoarthritis, depression, hyperparathyroidism, tobacco abuse, constipation, urinary and bowel incontinence who had been assigned consumer directed personal assistance services (CDPAS) for 46 hours per week. The patient had a fall with and had a left radial fracture. The patient saw her primary care physician (PCP) and the office note documented medical conditions with a plan for a referral to pain management and noted the patient needed paperwork filled out for a personal care aide. The patient was referred to a counselor for an evaluation of depression. The provider documented that the patient's COPD and pain limits her functioning, the patient needs to check her blood sugar 2-3 times a day and she needed assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient underwent an in-person assessment assessing the patient at a total assistance level with the task of ordinary housework while she was at a maximum assistance level with tasks of meal preparation, managing medication, shopping, transportation, and bathing. The patient was assessed at the extensive assistance level with tasks of stairs and upper and lower body dressing. The patient needed limited assistance for tasks of managing finances and personal hygiene. For the tasks of walking, locomotion, and toilet transfers the patient was assessed at a supervision level and was independent with tasks of phone use, toilet use, bed mobility, and eating. Notes from the assessment stated the patient lived alone, had moderately impaired cognitive skills, was afraid of being alone, had a decline in ADL status as well as a deterioration of overall self-sufficiency. The assessment also stated the patient used four incontinence briefs per day for bowel and bladder incontinence and could change the incontinence briefs but was not able to pull them up. 

The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient requires assistance with checking her blood sugar 2-3 times per day which would not be possible with the currently assigned CDPAS. The plan's own assessment stated the patient had a decline in her ADL status and deterioration of overall self-sufficiency in the last 90 days yet reduced services by 29 hours per week. The requested maintenance of 46 hours per week of CDPAS cannot be met solely with adaptive equipment and medical supplies. The requested CDPAS is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.