Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis

Treatment: consumer directed personal care assistance services (CDPAS) of 10 hours per day, 7 days per week for a total of 70 hours per week

The insurer denied coverage for consumer directed personal care assistance services of 10 hours per day, 7 days per week for a total of 70 hours per week

The denial is overturned.

This patient has an extensive medical history associated with significant functional impairment and needs assistance with all daily activities. She lives with her daughter who is her primary caregiver and was providing daily assistance when she was working from home due to the pandemic. The daughter has returned to work (outside of the home) and cannot provide care during the day. The patient is approved for Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week (daughter was CDPAS aide). As per the insurer's final denial letter, the daughter requested increase of services to 70 hours per week, which was denied. An external appeal was requested.

The functional status report for instrumental activities of daily living (IADL) indicates the patient was totally dependent for housework; she needed maximal assistance for meal preparation, shopping; extensive assistance for transportation, stairs; limited assistance for medications, finances, phone use, equipment use. For activities of daily living (ADL), patient needed extensive assistance for bathing, lower body dressing; and limited assistance for most other ADLs; except bed mobility and eating (set up help).

The Uniform Assessment System (UAS) noted short-term memory problem, and decision making for daily tasks was reported as modified independence (difficulty in new situations only). She was oriented to person, place and time, self-directing; able to verbalize her needs; communication (expression and comprehension) noted as clear. 

The patient's overall physical function appears to have declined significantly in recent months/weeks, which is probably the primary cause of her functional decline with daily activities. However, considering the patient's cognitive decline, it appears the patient needs caregiver assistance to manage her daily care needs safely and effectively as a result of both physical and cognitive impairment.

The patient has osteoarthritis which appears to have a significant effect on her mobility and routine function. The UAS noted she needs assistance with ambulation due to osteoarthritis. It was reported that she has limited range of motion (ROM) of upper and lower extremities; chronic pain in back and shoulders; difficulty bending and transferring, all of which can be at least partly due to osteoarthritis of upper and lower extremity joints and lumbar spine. Chronic pain and limitation of movement of upper and lower extremities and spine can adversely affect ability to perform all ADLs and most household related tasks.

The patient has diabetes mellitus type 2 with episodes of low blood sugar (passes out). This is a serious and potentially critical problem, which may be at higher risk recently due to the patient's decreased appetite. 

The patient has been receiving personal care services as CDPAS with her daughter as personal assistant (PA). Now that the daughter is not home during the day, she cannot serve as CDPAS PA. It is not clear from the available records whether another person has been identified to serve as CDPAS PA, or if the family plans to use standard personal care assistance (PCA) services. The recommendation from this review for personal care services 70 hours per week is applicable for CDPAS or PCA services.

Personal Care Services 10 hours per day, 7 days per week, total of 70 hours per week which can be used as Consumer Directed Personal Assistance Services or Personal Care Assistance Services, or combination of both is medically necessary.

The insurer's denial of coverage for the requested Consumer Directed Personal Care Assistance Services of 10 hours per day, 7 days per week for a total of 70 hours per week is reversed. Medical necessity is substantiated.