Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension/High Blood Pressure
Treatment: Home Health Care/Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week
The health plan denied the requested Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week as not medically necessary.
The health plan's determination is overturned.

The patient is a male with a past medical history of congestive heart failure, hypertension, bilateral hearing loss, asthma, urinary incontinence, and intellectual disability who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 4 hours/day, 5 days/week, to total 20 hours/week based on assessment performed via telephone, assessing the patient at total assistance with managing finances while maximum assistance with tasks of meal preparation, ordinary housework, managing medication, and shopping. With tasks of phone use and equipment management the patient was assessed at extensive assistance while supervision with tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, toilet use, and eating. The patient was assessed at independent with tasks of transfer toilet and bed mobility. The patient was hospitalized with sepsis, pneumonia, acute kidney injury, and an elevated troponin. There was a request to increase CDPAP services and the patient underwent a video assessment assessing the patient at total assistance with task of managing finances while maximum assistance with tasks of meal preparation, ordinary housework, managing medication, and shopping. With tasks of phone use, stairs, and transportation, the patient was assessed at extensive assistance while limited assistance with tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient was assessed at supervision with assistance with eating. Notes from the assessment stated the patient had a decline in activities of daily living (ADL) status over the last 90 days and a deterioration of overall self-sufficiency in the last 90 days. At issue is the medical necessity for the requested health service/treatment of Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week.

The health plan's determination of medical necessity is overturned, in whole.

There is documentation of the medical necessity for the patient's need for increased assistance with ADLs and instrumental activities of daily living (IADLs) from both his cardiologist and his primary care physician. The universal assessment noted an increased need for assistance with tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient requires at least limited assistance with tasks of walking, locomotion, transfer toilet, and toilet use. The patient therefore has unpredictable and unscheduled care needs that span a continuum of time. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. 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 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this 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.