Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied CDPAP services 12 hours per day 7 days per week split shift for a total of 168 hours per week. 
The denial is overturned in whole.

The patient is a female with past medical history of hypertension, breast cancer, diabetes mellitus type 2, osteoarthritis, stroke, urinary incontinence, bowel incontinence, and Alzheimer's dementia who was assigned 6.5 hours/day of Consumer Directed Personal Assistance Services (CDPAS) services. The patient was assessed at total assistance with tasks of meal preparation, ordinary housework, and managing finances while maximal assistance with tasks of managing medication, shopping, transportation, bathing, and dressing lower body. In addition, the patient was assessed at extensive assistance with tasks of stairs, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use while limited assistance with task of bed mobility. The patient was assessed as independent with task of eating. The notes from the telephonic assessment noted the patient lived with her daughter and her daughter's family.

The patient was hospitalized with diagnosis of embolic cerebrovascular accident (CVA) with resultant aphasia, dysphagia, and functional quadriplegia. The patient had gastrostomy (G)-tube placed. The patient was transferred to rehabilitation with plan to discharge to home with increase in CDPAS hours. The patient had a telephonic assessment tool assessing the patient at total assistance with all assessed activities of daily living (ADL)/instrumental activities of daily living (IADL) tasks. The notes from the telephonic assessment stated the patient was still residing in the rehabilitation facility, had no informal helpers, would have an electric bed and Hoyer lift at discharge to home, was unresponsive to tactile stimuli, needed turning and repositioning every 2-4 hours, required 2 people for Hoyer lift transfers, and had an open area on buttock.

The subject under review is the medical necessity for increase in consumer directed personal assistance program services 12 hours per day, 7 days per week: 12 hours per day 7 days per week (split shift) for a total of 168 hours per week.

The health plan's determination is overturned in whole.

The patient had significant change in her functional status following a CVA. The patient was aphasic, quadriplegic, and required G-tube feeding and medication administration. The patient's attending physician documented the need for total assistance with all ADLs/IADLs and the need for turning and repositioning every 2 hours. The patient had 24 hour care needs.  The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient in safe completion of ADL/IADL tasks. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's statement, and the applicable and generally accepted practice guidelines, an increase in CDPAS services is 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.