Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Varicose Veins
Treatment: Home Health Care
The health plan denied the requested increase in CDPAS hours. The health plan's determination is overturned.

The patient is a female with a past medical history of varicose veins, venous insufficiency, edema, abnormal gait, fibromyalgia, chronic dizziness, obesity, neuropathy, tobacco abuse, arthritis of the neck and back, gastroesophageal reflux disease (GERD), depression, and urinary incontinence who had been assigned consumer directed personal assistance service (CDPAS) hours 4 hour/day, 7 days/week, to total 28 hours/week based on telephonic assessment tool. The patient was assessed at maximum assistance with tasks of meal preparation and ordinary housework while extensive assistance with stairs, shopping, and transportation. The patient was assessed at limited assistance with tasks of phone use, equipment management, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and eating while supervision with task of managing medication. The patient was assessed at set up only for managing finances and independent with bed mobility. Notes from the assessment stated the patient stated she needed help to get things done because she did not feel good, lived with her child, was occasionally incontinent, and had 12 hours of informal care in the last three days. The patient's provider requested to increase CDPAS hours and the patient underwent another telephonic assessment tool, assessing her at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, bathing, and dressing lower body. The patient was assessed at limited assistance with tasks of managing finances, equipment management, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. With the task of managing medication, the patient was assessed at supervision only. Notes from the assessment stated the patient was dyspneic when performing moderate activities, has a teenage child as informal helper with no alternate informal helper, and had 6 hours of informal help in the last three days. At issue is the medical necessity of the requested increase in CDPAS hours.

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

Yes. The patient had documented worsening in walking, locomotion due to bilateral foot pain as well as documented increase in assistance needs with tasks of managing finances, shopping, bathing, dressing lower body, and bed mobility when comparing one assessment to the second assessment tool. The patient scored 14/20 on Mini-Mental State Examination (MMSE). There is documentation the patient has a teenage child as informal support and requires assistance with all activities of daily living (ADLs) / instrumental activities of daily living (IADLs) tasks outside of the time that an informal helper is able to assist her. The patient does have urinary incontinence which is unscheduled and unpredictable, and the patient requires assistance with walking, locomotion, transfer toilet, toilet use, and personal hygiene during these unpredictable and unscheduled episodes. The increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Considering the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 8 hours/day, 7days/week, to total 56 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.