Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vertigo. 

Treatment: Consumer Directed Personal Assistance Services (CDPAS) of 49 hours per week. 

The insurer is denied coverage for Consumer Directed Personal Assistance Services (CDPAS) of 49 hours per week.

The denial is overturned. 

This female patient has history of post-traumatic stress disorder, dementia, vertigo, migraines, hypertension, diabetes, heart disease, lower back pain, and a history of falls.  Her physician indicated that she needs assistance with all daily living activities. Her ambulation is worse. She has worsening shortness of breath, balance problems, generalized weakness, and pain in the spine and knee. She has limited range of motion of her shoulders due to severe arthritis. She has urinary incontinence. The patient needs total assistance with food preparation and monitoring food intake. The physician recommends increasing home care. The patient's neurologist stated that she has had memory decline over 7 years. She has periodic confusion, aggressiveness and delusions. She is unable to care for herself, including cooking, shopping, paying bills; needs reminders for activities of daily living (ADLs.) She has been falling at night when attempting to stand and use the bathroom. She lives alone with 5 hours assistance. More hours are needed for safety and mental stability, especially in the evening and night; 12-24 hours.

The insurer approved Home Care/Personal Care HHC Level 2 Personal Care Services per 15 minutes 25 hours per week. The patient is receiving personal care services as Consumer Directed Personal Assistance Services (CDPAS). The patient requested increase of Home Care/Personal Care HHC - Level 2 Personal Care Services per 15 minutes to 49 hours per week, which was denied. Appeal was requested. The final decision upheld the denial for increase of personal care services because it is not medically necessary. Approval stays at personal care services 25 hours per week. The reason for denial was noted as follows: Based on the nursing assessments the patient's function improved with some instrumental ADLs; and declined in some other ADLs and IADLs.  There were some changes in the patient's medical diagnoses and medications, but there were no falls or hospitalizations/Emergency Department (ED) visits. Letter of medical necessity notes that patient needs assistance with all ADLs. The patient is receiving more hours than her tasking tool estimate. Plan assessments are not required to include safety monitoring as a separate task for falls. There is no medical necessity to increase the patient's care hours beyond 25 hours per week. Community friend requested an external appeal on behalf of the patient.

Home Care/Personal Care HHC - Level 2 Personal Care Services per 15 minutes 49 hours per week is medically necessary. The patient has been receiving personal care services as CDPAS. This recommendation for approval of 49 hours per week applies to either CDPAS or PCA services, depending on which type of plan will be implemented.

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

The carrier's denial of coverage for the requested Home Care/Personal Care HHC - Level 2 Consumer Directed Personal Assistance Services (CDPAS) of 49 hours per week is overturned.  The medical necessity is substantiated.