Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 6 hours per day - 7 day(s) per week - for a total of 42 hours per week.
The insurer denied: Consumer Directed Personal Assistance Program (CDPAP): 6 hours per day - 7 day(s) per week - for a total of 42 hours per week.
The denial is overturned.

The patient is a male with a medical history notable for dementia, congestive heart failure, diabetes, chronic kidney disease stage 4, chronic obstructive pulmonary disease, and chronic back pain. The patient receives 3 hours per day, 7 days per week (21 hours per week) of Consumer Directed Personal Assistance Program (CDPAP) services. The patient and his care team requested an increase to 6 hours per day, 7 days per week (42 hours per week).

A letter of support for this appeal was provided by the treating physician. The letter states that the patient's current allotment of 3 hours per day is insufficient to meet his personal care needs and does not take into account his need for assistance early in the morning. The patient has dementia with the most recent Montreal Cognitive Assessment (MOCA) score of 18/30, which leads to delays in completing activities of daily living (ADLs). He has mobility challenges and requires a walker to ambulate. Grooming, dressing, and hygiene are challenging due to his low endurance from his multiple medical problems. He often skips meals because of the physical effort and coordination required to reheat meals. This has led to challenges in controlling his heart failure and diabetes, which rely on fairly consistent salt and carbohydrate intake. He has help from family, but it is insufficient to meet his needs. Therefore, the physician attests that the patient requires additional personal care hours.

A Uniform Assessment System (UAS) was completed and was available for review. Cognition was noted to be minimally impaired. He was alert and oriented times three, with 2/3 word recall after 5 minutes. He can describe the steps of boiling water but has a history of forgetfulness including forgetting to turn the stove off. From a functional standpoint, he requires total dependence on housework. He requires maximal assistance for meal preparation, managing medications, and shopping. He requires extensive assistance in managing finances. For his ADL's, he requires extensive assistance for bathing, dressing his upper/lower body, walking, locomotion, and toilet transfer. He requires limited assistance for toilet use, bed mobility, and eating. He is frequently incontinent of urine (daily, with some control present) and the continent of stool. Compared with a prior UAS, he showed a functional decline.

The health plan's determination is overturned.

The requested service of the Consumer Directed Personal Assistance Program (CDPAP): 6 hours per day - 7 days (s) per week - for a total of 42 hours per week is medically necessary for this patient.

The patient has multiple medical problems which impact his functional status, and his overall function will be affected by his dementia. He has shown a decline over the past year. The physician attested to multiple reasons why his current allotment of CDPAP hours is insufficient to meet his personal care needs. This is not surprising given that his tasking tool recommended 35 hours per week, which could be seen as a minimum to complete all of his personal care tasks. He is currently only receiving 21 hours per week. Realistically it may take longer than the 35 hours that was recommended for the reasons that his physician stated which leads to delays in completing personal care tasks. These additional hours are intended to complete personal care functions and are not solely for the purpose of safety monitoring and security.