Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, Osteoarthritis, Polyneuropathy, Chronic obstructive pulmonary disease (COPD)
Treatment: 27 hours of Consumer Directed Personal Assistance Services (CDPAS) per week
The insurer denied coverage for 27 hours of CDPAS per week. 
The denial is overturned. 

This is a male patient who lives at home with his son. The patient has several chronic medical conditions.  He has functional impairment affecting his ability to perform daily activities. He receives personal care services, provided as Consumer Directed Personal Assistance Services (CDPAS) 27 hours per week. The patient's son is the CDPAS aide.  The insurer informed the patient that due to a clerical error, 5 hours of mutual aide were not previously deducted (as per the insurer's final denial letter if a person does not live alone, hours are deducted for mutual aide). Therefore, the patient's CDPAS hours were reduced to 22 hours per week.  

The patient's functional status as reported in the Uniform Assessment System (UAS) report indicates the patient needs extensive assistance with meal preparation, ordinary housework and shopping. For Activities of Daily Living (ADLs), he needs extensive assistance with bathing, lower body dressing; limited assistance with toileting (transfer and use); supervision for walking, personal hygiene, upper body dressing; setup help with eating. The patient has a few medical conditions that most likely contribute to his functional impairment and need for assistance with daily activities, including: osteoarthritis, polyneuropathy, chronic obstructive pulmonary disease (COPD), and diabetes mellitus. 

Based on the records provided for review, the patient has functional impairment due to his medical conditions and needs some degree of support with most daily activities to ensure that he completes all ADLs safely and effectively, has a home environment that is safe and clean, and receives proper and adequate nutrition, especially with the need to achieve and maintain adequate glucose control for diabetes. Therefore, it is medically necessary for the patient to have a caregiver provide adequate support for the patient's personal care needs each day. The tasking tool associated with the UAS report did not appear to allocate sufficient time for various ADLs and Instrumental Activities of Daily Living (IADLs). With some modification, the total CDPAS hours are 34.35 hours per week.  With the insurer's 5 hour deduction for mutual or shared services, the total hours per week are 29.35. Therefore, there does not appear to be justification to decrease CDPAS hours to 22 hours per week. The maximum number of hours approved from this review is limited by the number of hours requested (as per the insurer's final adverse determination notice) i.e. 27 hours per week. The next re-assessment will determine whether the patient's personal care needs are adequately met with CDPAS 27 hours per week, or if the plan needs to be modified.

CDPAS 27 hours weekly is medically necessary. The healthcare plan did not act reasonably with sound medical judgement, and in the best interest of the patient.

The carrier's denial of coverage for the requested 27 hours of CDPAS per week is overturned. The medical necessity is substantiated.