Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Radiculopathy, Rotator Cuff Repair.
Treatment: Consumer directed personal assistance program (CDPAP): 6 hours per day for 4 days per week for a total of 24 hours per week. 

The insurer denied the request for CDPAP: 6 hours per day for 4 days per week for a total of 24 hours per week. 

The health plan's determination is overturned. 

The patient is a male with a past medical history of osteoarthritis, migraines, hypertension, lumbar radiculopathy, urinary incontinence, insomnia, and constipation. He had been assigned consumer directed personal assistance program (CDPAP) services for 4 hours/day, 4 days/week, to total 16 hours/week based on an assessment performed via video. This assessment showed the patient at maximum assistance with tasks of managing medication and shopping while extensive assistance with tasks of meal preparation and ordinary housework. With tasks of transportation, bathing, dressing upper/lower body, walking, locomotion, toilet transfers, toilet use, and bed mobility the patient was assessed at limited assistance while supervision with tasks of managing finances and stairs. The patient was assessed at set up with task of phone use. The tasking tool estimated 16 hours/week. 
The patient's neurologist provided a letter diagnosing the patient with left shoulder and right elbow internal derangement consistent with radiculopathy. The letter stated the patient was totally disabled and required home health care hours and extended for the patient's daily activities. The patient's orthopedist provided a note stating the patient had left shoulder rotator cuff repair and would start active and passive range of motion at physical therapy. There was a request to increase CDPAP services and the patient underwent an assessment via video assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing medication, and shopping. With the tasks of stairs, transportation, bathing, and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of dressing upper body, walking, locomotion, toilet transfers, toilet use, bed mobility, and eating. Notes from an assessment stated the patient lived alone, had a decline in activities of daily living (ADL) status over the last 90 days, and had a deterioration in overall self-sufficiency in the last 90 days. Tasking tool estimated 18 hours/week. 

Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 6 hours/day, 4 days/week, to total 24 hours/week are medically necessary for this patient. The plan's assessment documented an increase in assistance needs with tasks of meal preparation (from extensive to maximum), ordinary housework (from extensive to total), stairs (supervision to extensive), transportation (limited to extensive), bathing (limited to extensive), personal hygiene (independent to limited), dressing lower body (limited to extensive), and eating (independent to limited) when comparing the previous assessment to the most recent assessment. Despite the plan's own assessment documenting this increase in assistance needs the tasking tool only increased CDPAP service hours by 2 hours/week.
The plan's assessment underestimated the patient's assistance needs with toilet transfers and toilet use as the patient had recent surgery on his shoulder. In addition, it was assumed that the patient had informal help from his sons which who no longer available. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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 his own home.