Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, hyperlipidemia, hypothyroidism, and osteoarthritis.

Treatment is Consumer Directed Personal Assistance Program (CDPAP); 6 hours per day - 5 days per week; 5 hours per day - 2 days per week - a total of 40 hours per week.

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP); 6 hours per day - 5 days per week; 5 hours per day - 2 days per week - a total of 40 hours per week.
 
The denial is overturned.

This patient has extensive medical history associated with functional decline and needs help with most daily activities. The patient lives alone. The UAS (uniform assessment system) did not identify informal helpers. The patient relies on personal care services for help with IADLs (instrumental activities of daily living) and ADLs (activities of daily living). The UAS indicates the patient was receiving personal care aide (PCA) services. The insurer's final denial letter and Clinical Review Checklist refer to services as Consumer Directed Personal Assistance Program (CDPAP). The patient has been receiving personal care services 26 hours per week 3 or 4 hours per day, 7 days per week. As per the UAS, the patient was attending social day care (SDC) 4 hours per day, 3 days per week (current attendance at SDC is not noted in available records). The patient requested an increase of CDPAP services to 40 hours per week (5 or 6 hours per day, 7 days per week), which was denied. External appeal was requested. 

The most recent UAS provided was reviewed. The functional status report for IADLs indicate the patient needs maximal assistance for meal preparation, ordinary housework, shopping; extensive assistance for stairs, and transportation; supervision for managing finances and medications; setup help for phone use. For ADLs, the patient needs extensive assistance for bathing, dressing lower body; limited assistance for personal hygiene, dressing upper body, bed mobility; supervision for walking, locomotion, toilet transfer; setup help for toilet use, and eating.

Depression in the elderly is associated with functional decline, and various symptoms, e.g., fatigue, decreased appetite, poor sleep. The UAS medication list includes fluoxetine. It is noted the patient has psychotherapy monthly. Anxiety may limit a person's participation in certain daily tasks. Comments in the Clinical Review Checklist indicate the patient wants additional aide services to assist her with walking, especially outside, as she is afraid of falling.

The information provided for review supports the patient's need for additional personal care services. The patient depends on personal care services for various levels of support with all daily activities, including IADLs, routine ADLs
(bathing, dressing, eating, personal hygiene), and ADLs that occur at various unscheduled times throughout the day (i.e., toileting, transfers, ambulation). Most
likely, the level of assistance the patient need varies depending on frequency and severity of symptoms (as described in the records and reviewed in this report). Considering the patient's medical history, symptoms, and functional status, it is medically necessary for the patient to have caregiver support for a more extended period of the day to help prevent adverse health and safety events, e.g., falls/injury, skin damage due to inadequate toileting/incontinence care, insufficient food and fluid intake, and hypoglycemia.

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

The insurer's denial of coverage for the Consumer Directed Personal Assistance Program (CDPAP); 6 hours per day - 5 days per week; 5 hours per day - 2 days per week - a total of 40 hours per week is overturned. Medical Necessity is substantiated.