Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, memory loss, age-related physical
debility, sciatica, neuropathy, lumbago and
osteoarthritis
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Live-In, per Diem, 24 Hour(s) per Day, 7 Day(s) per Week
The insurer denied the Consumer Directed Personal Assistance Program (CDPAP) Live-In, per Diem, 24 Hour(s) per Day, 7 Day(s) per Week
The denial is overturned.

This male has conditions including diabetes, memory loss, age-related physical debility, sciatica, neuropathy, lumbago and osteoarthritis,  He is appealing denial of consumer directed personal assistance program (CDPAP), live-in, seven days per week. He has been approved for consumer directed personal assistance program 56 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with housework, managing finances, walking, and toilet transfer; maximal assistance with meal preparation, managing medications, shopping, bathing, lower body dressing, locomotion, toilet use, and bed mobility; extensive assistance with personal hygiene, and upper body dressing; limited assistance with phone use; and independent with eating.  He is frequently incontinent of bowel and bladder.  Compared to Uniform Assessment System evaluation completed the previous year, there has been a decline in cognition and ability to manage finances, lower body dressing, locomotion, toilet transfer and bed mobility.  The patient has had more bowel incontinence.  An appeal letter from a Nurse Practitioner (NP) states the patient is bed-restricted due to sciatica, severe neuropathy and lumbago.  Home care aide states the patient needs constant 24 hours care because he is completely bedridden.  He requires a Hoyer lift for transfer.  It states when arriving in the morning, the patient's diaper is filled with urine and excrement.  It also, notes he has fallen out of the bed.  A letter from the social worker (SW) notes the patient needs 24 hour assistance due to inability to transfer and ambulate independently.  A statement from recommends 24 hour, live-in, care based on the patient being bedbound and need for assistance with activities of daily living (ADLs) and already accounted for in the Uniform Assessment System evaluation.

Yes, the proposed treatment is medically necessary.
The proposed treatment is medically necessary because it is consistent with standard of care.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding.  Personal care service is necessary when assistance cannot be met from use of from informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  

This patient has multiple chronic conditions including memory loss and weakness that has resulted him being bedbound.  He is appealing denial of consumer directed personal assistance program (CDPAP), live-in, seven days per week. He has been approved for consumer directed personal assistance program 56 hours per week. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs) except eating.  Compared to Uniform Assessment System evaluation completed last year, there has been a decline in cognition and ability to manage finances, lower body dressing, locomotion, toilet transfer and bed mobility.  He is incontinent of bowel and bladder.  Appeal letters note the patient is bedbound and requires a Hoyer lift for transfer to wheelchair.  He has no assistance during nighttime with bed mobility and toileting.  He also has a history of falling.  This patient has demonstrated the need for extensive assistance with ambulation/transfers for toileting during day and night.  This patient has continuous needs that cannot be met with the approved consumer directed personal assistance program 56 hours per week.  The proposed increase in consumer directed personal assistance program to 24 hours, live-in, per day is medically necessary to meets this patient's need for assistance with activities of daily living (ADLs) and personal care.