Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke. 
Treatment: Consumer directed personal assistance program (CDPAP): 8 hours per day, 7 days per week- total of 56 hours per week. 

The insurer denied the consumer directed personal assistance program (CDPAP): 8 hours per day, 7 days per week- total of 56 hours per week. 

The health plan's determination is overturned. 

The patient is a male with a past medical history of bilateral foot amputations, peripheral vascular disease, osteoarthritis and gastroesophageal reflux disease (GERD). He also has a medical history of shortness of breath, dizziness, urinary incontinence, diabetes mellitus type 2, spinal stenosis, hypertension and chronic kidney disease. He was hospitalized with a cerebrovascular accident (CVA) with left hemiparesis. The patient was transferred to rehabilitation after his hospitalization. There was a request to start consumer directed personal assistance program (CDPAP) services and the patient underwent an assessment. The patient was assessed at total assistance with the tasks of ordinary housework while he was maximum assistance with the tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, dressing lower body, walking, locomotion, toilet transfers and bed mobility. For the tasks of personal hygiene, dressing upper body, and toilet use the patient was assessed at extensive assistance while limited assistance was needed with the tasks of managing finances and eating. The patient was assessed at set up only with the task of phone use. 

The notes from the assessment stated that the patient lived with a friend, had daily bladder incontinence and used diapers and incontinence (Chux) pads. He had a right foot amputation several years ago however the surgical wound was not completely healed. The tasking tool estimated 45.5 hours per week. 

The insurer sent an initial adverse determination denial notice stating the plan had approved CDPAP services 4 hours per day, 7 days per week to total 28 hours per week. The patient's provider requested approval for 8 hours per day, 7 days per week, to total 56 hours per week but the plan continued to approve 4 hours per day, 7 days per week, to total 28 hours per week. The plan stated they made a recommendation for physical therapy and speech therapy as well as adjusting service hours to better suit the patient's care needs. 

The insurer sent a final adverse determination denial notice partially denying request the to increase CDPAP services approving 6 hours per day, 7 days per week to total 42 hours per week. The patient appealed denial decision. 

The requested health service and treatment of consumer directed personal assistance program (CDPAP): 8 hours per day, 7 days per week for a total of 56 hours per week is medically necessary for the patient. There is documentation of a recent CVA with left sided hemiparesis. The patient was noted to require at least extensive assistance with the tasks of walking, locomotion, toilet transfers, and toilet use. Therefore, the patient has unpredictable and unscheduled care needs that span a continuum of time. The insurer failed to document a plan to meet these unpredictable and unscheduled care needs when the patient doesn't have informal help. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 8 hours per day, 7 days per week, to total 56 hours per week are medically necessary for the patient. 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 his own home.