Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, Multiple fractures, End stage renal disease on hemodialysis

Treatment: Consumer Directed Personal Assistant Services (CDPAS) 55 hours per week

The insurer denied coverage for Consumer Directed Personal Assistant Services (CDPAS) 55 hours per week.

The denial is overturned.

This is a female patient with an extensive medical history including anxiety, chronic obstructive pulmonary disease (COPD), cancer, coronary heart disease (CAD), depression, hip fracture, other fracture, osteoporosis, anemia, anxiety, constipation, end stage renal disease (ESRD) on hemodialysis, hypertension, gastroesophageal reflux disease (GERD), falls, hypothyroidism, insomnia, major depressive disorder, nausea, chronic pain, hammer toe, systemic sclerosis, lupus, rheumatoid arthritis, sicca syndrome, spinal stenosis and wedge compression fracture. In recent months, the patient's functional status has been further compromised by falls resulting in fractures. The patient lives alone. She receives Consumer Directed Personal Assistant Services (CDPAS), 45 hours per week. She requested an increase of CDPAS hours to 55 per week which was denied.  

The patient's cognition as noted in Uniform Assessment System (UAS) documentation indicates that she is self-directing and oriented x 3. However, there are some signs of possible cognitive decline. The patient's decision making capacity is noted as minimally impaired; in some situations decisions are poor or unsafe. The UAS functional assessment indicated that the patient was totally dependent on caregiver assistance for housework and stairs; needed maximal assistance for meal preparation, shopping, transportation; and extensive assistance with finances and medication. Regarding Activities of Daily Living (ADLs), the UAS indicates that the patient needs maximal assistance for lower body dressing; extensive assistance for bathing, walking/locomotion, toilet transfer, toilet use; limited assistance for lower body dressing, bed mobility; supervision for personal hygiene; and setup help for eating. 

The patient has multiple medical conditions and associated symptoms that most likely contribute to physical impairment and have a substantial effect on her daily function. When a person has multiple symptoms interfering with daily function, including pain, fatigue, and dyspnea, the effort of performing each task can be associated with stress; both physical and mental. The UAS indicates that the patient is experiencing some depression and anxiety due to her health and functional limitations. Providing adequate assistance with daily activities can at least help relieve some of the physical stress and possibly some of the anxiety associated with loss of function for routine tasks.

Considering the patient's medical history and associated symptoms limiting her physical functional ability, plus some concern for her safety judgment when performing daily activities, it is medically necessary and in the patient's best interest to have a caregiver present to assist with daily activities throughout the day. The UAS did not identify informal caregivers who provide assistance on a regular basis. Therefore, personal care services (in this case CDPAS) are indicated to provide assistance with daily activities when needed. The patient goes to dialysis 3 days per week, a few hours per session. Her aide does not stay with her during dialysis sessions. The patient is requesting 10 additional CDPAS hours per week. These hours can be distributed during non-dialysis hours that best accommodate the patient's needs. There is still some concern about all the hours the patient is alone each day, including performance and safety of evening/nighttime ADLs.  

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

The medical necessity for CDPAS 55 hours per week is substantiated. The insurer's denial is overturned.