Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:Cardiac/Circulatory Problems/Coronary Artery Dusease/CAD
Treatment: Home Health Care/Consumer directed personal assistance program (CDPAP) 9 hours per day - 6 days per week for a total of 54 hours per week.
The health plan denied the requested Home Health Care/Consumer directed personal assistance program (CDPAP) 9 hours per day - 6 days per week for a total of 54 hours per week as not medically necessary. The health plan's determination is partially overturned.

This is a case review for a male with a medical history notable for coronary artery disease, hypertension, and hypothyroidism. The patient is approved for 3 hours per day, 5 days per week (15 hours per week) of Consumer Directed Personal Assistance Program (CDPAP). The patient and his care team requested an increase to 9 hours per day, 6 days per week (54 hours per week).
The patient's nephew provided a letter of support for this appeal. The letter states that the patient has a hard time standing and walking due to a history of back problems and back surgery. The letter states that the patient is not able to do things on his own anymore. He requires assistance for dressing, cooking, and bathing. The patient is left alone several hours per day due to lack of personal care assistance.
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient has diabetes mellitus, hypertension, hypothyroidism, and osteoarthritis. He was also recently admitted with chest pain and found to have occlusive coronary artery disease. The provider requests assistance with cooking, housekeeping, and mobility supervision. The letter states that he cannot walk for prolonged periods of time. The letter states that the request is due to his recent diagnosis of coronary artery disease.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient lives alone in an apartment. The patient was alert and oriented but forgetful at times. He is able to direct his own care. His recall was 2/3 at five minutes. His procedural memory was intact. For his instrumental activities of daily living (IADL), the patient requires total dependence for housework. He requires maximal assistance for meal preparation and shopping. He requires extensive assistance for medications, stairs, and transportation. For his activities of daily living (ADL), he requires extensive assistance for bathing and dressing lower body. He requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. He is independent for bed mobility and eating. He is infrequently incontinent of urine and continent of stool. He wears Pull-Ups for incontinence care. A task tool associated with the assessment recommended 4 hours per day, 5 days per week (20 hours per week) to address his personal care needs. They recommended two days of social daycare services per week. Compared to a prior UAS, the patient showed a modest decline in functional capacity.
At issue is the medical necessity for the requested health service/treatment of consumer directed personal assistance program (CDPAP) 9 hours per day - 6 days per week for a total of 54 hours per week.

The health plan's determination of medical necessity is overturned in part. The plan should approve an increase to 4 hours per day, 7 days per week (28 hours per week) to ensure the patient's personal care needs are being met.

The requested health service of consumer directed personal assistance program (CDPAP) 9 hours per day - 6 days per week for a total of 54 hours per week has not been demonstrated to be medically necessary for this patient.
An updated assessment was completed following the patient's recent clinical event. This assessment does demonstrate a functional decline. The task tool recommended 4 hours per day to address the patient's personal care needs. He should be provided with these four hours of services every day of the week to ensure that his personal care needs are being met. There is insufficient evidence that the requested increase to 9 hours per day is medically necessary. The patient requires assistance with most instrumental activities of daily living but is independent or requires only light touch assistance for most activities of daily living. The letters request assistance with meal preparation, housekeeping, and bathing which are accounted for in the task tool's recommendation of 4 hours per day. The plan should approve an increase to 4 hours per day, 7 days per week (28 hours per week) to ensure the patient's personal care needs are being met.