Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease, breast cancer, coronary heart disease, stroke, and atrial fibrillation

Treatment is consumer directed personal assistance program (CDPAP): 24 hours per day - live in per diem - 7 days a week

The insurer denied coverage for consumer directed personal assistance program (CDPAP): 24 hours per day - live in per diem - 7 days a week
 
The denial is overturned

This case involves a patient seeking authorization of coverage for consumer directed personal assistance program, 24 hours/day, living per diem, 7 days a week. The patient had a history of chronic obstructive pulmonary disease, breast cancer, coronary heart disease, stroke, and atrial fibrillation.

It was noted that she required maximal assistance with meal preparation, managing medications, equipment management, bathing, dressing of the lower body, and toilet transfers. She required total dependence with ordinary housework. She required extensive assistance with personal hygiene, walking, bed mobility, and dressing the upper body. She had a history of falls. It was reported that she was incontinent.

Per the referenced sources, medical necessity services are those that will or are reasonably expected to prevent the onset of illness, condition or disability, will or are reasonably expected to reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, disability, will assist the patient to achieve or maintain maximum functional capacity in performing daily activities, and will provide the opportunity for a patient to have access to the benefits of community living to achieve person centered goals, and live and work in the setting of their choosing. The use of personal assistance is crucial for patients with disabilities to allow them to remain in the community as opposed to being placed in institutional settings. In this case, it was noted that the patient had breast cancer, severe degenerative and autoimmune joint disease, thrombophilia with pulmonary emboli, gait disturbance due to cerebellar ataxia, peripheral neuropathy, sleep apnea, chronic obstructive pulmonary disease, and depression she had a severe gait disturbance.  It was stated that the patient's symptoms had worsened within the past 2 years. She required assistance for ambulation, toileting, dressing, transfers, and was unable to change her own incontinence supplies. Her treating provider noted that she needed assistance during the day and during the night. She was extremely high risk of serious injury due that could be life-threatening with falls due to being on anticoagulation therapy. It was noted that she was not taking her medications as prescribed and
that her caregiver had to take over completely managing the medications. They requested consumer directed personal assistance program, 24 hours/day, living per diem, 7 days a week is medically necessary for this patient. As noted in the literature, use of personal assistance is crucial for patients with disabilities to allow them to remain in the community as opposed to being placed in institutional settings. The patient requires repositioning and assistance with ambulation throughout the night. This addresses a functional need. The patient requires full assistance for ambulation and hygiene care. This would occur during the day and at night. A lower level of care places the patient at further risk of deterioration from inability to meet needs and risk of injury. Thus, the 24 hours/day care is medically necessary for this patient. As such, the denial of coverage for consumer directed personal assistance program (CDPAP) for 24 hours per day -live in per diem-7 days a week was not appropriate and is overturned.

The insurer's denial of coverage for consumer directed personal assistance program (CDPAP): 24 hours per day - live in per diem - 7 days a week is overturned. Medical Necessity is substantiated.