Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-kyphoscoliosis, osteoporosis, osteoarthritis.
Treatment: Home Health Care. 
The insurer denied personal assistance services for medical necessity. 
The denial was overturned. 

The patient is a female with a past medical history of kyphoscoliosis, osteoporosis, osteoarthritis, chronic obstructive pulmonary disease (COPD), vasovagal syncope, chronic infection of hernia repair mesh, hypothyroidism, mild cognitive impairment, and urinary incontinence who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 6 hours/day, 5 days/week, to total 30 hours/week. 
The patient's primary care physician (or provider) (PCP) provided a letter stating the patient had kyphoscoliosis and widespread osteoarthritis and required more help in her home. The letter also stated the patient had COPD which limited her ability to comfortably move around as well as urinary incontinence with the requirement of help with toileting. In addition, the PCP letter noted the patient had chronically infected mesh in her chest from a previous hernia repair and had multiple wounds which were managed with topical antibiotics and a dry dressing.
The insurer sent final adverse determination denial notice denying request to increase CDPAP services and noted they had corrected the documentation following the letter that the daughter had sent. The denial further stated the additional hours would be for supervision as a stand-alone, which was not covered by the plan.
At issue is the medical necessity of Consumer directed personal assistance services; 40 hours per week, 8 hours per day, 5 days per week.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Consumer directed personal assistance services; 40 hours per week, 8 hours per day, 5 days per week, is medically necessary for this patient.
The patient has documented chronic and progressive medical conditions of kyphoscoliosis, osteoarthritis, and cognitive impairment. The patient requires at least some assistance with all ADLs(Activities of daily living) and IADLs except eating. The patient has assistance needs with all walking and locomotion as well as transfer to the toilet and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The current CDPAP hours and/or adaptive equipment and/or medical supplies are not sufficient to meet the patient's care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of all ADLs and IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 8 hours/day, 5 days/week, to total 40 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Therefore, the requested health service of Consumer directed personal assistance services; 40 hours per week, 8 hours per day, 5 days per week, is medically necessary.