Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus
Treatment: Consumer Directed Personal Aide Service (CDPAS) 7 days x 7 hours.
The insurer denied the Consumer Directed Personal Aide Service (CDPAS) 7 days x 7 hours.
The determination is overturned.

The patient had a past medical history of osteoarthritis, diabetes mellitus type 2 on insulin, hypertension, gastroesophageal reflux disease (GERD), urinary incontinence, age related cognitive decline, chronic anticoagulation who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 5 hours/day, 7 days/week to total 35 hours/week based on assessment tool. The patient was assessed at maximum assistance with meal preparation, ordinary housework, stairs, shopping, and transportation while extensive assistance with tasks of managing finances, managing medication, phone use, bathing and dressing lower body. With tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet and toilet use the patient was assessed at limited assistance while independent with tasks of bed mobility and eating.
The patient had another assessment performed via telephone assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, shopping, and transportation while extensive assistance with tasks of managing finances, managing medications, phone use, stairs, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. With the tasks of bed mobility and eating the patient was assessed as independent. Notes from the second assessment stated the patient needs assistance with toileting and incontinence care.
The son sent a letter to insurer stating the patient's ability to care for herself had declined, her mobile ability and her memory are weakening, she requires insulin shots twice daily, requires increased time for meal preparation and eating as she requires more supervision with eating, and requires additional supervision for bathroom and toileting in the evenings. The plan sent a final adverse determination denial notice stating the request to increase CDPAP services did not meet criteria and was not medically necessary. The plan denial stated in order to have an increase in CDPAP services there must be a documented significant change in functional status requiring additional time and assistance to complete activities. The plan denial stated the patient should consider physical therapy (PT) for maintenance and optimization of functional status. The patient's son provided a letter stating the patient had been having an increase in hearing loss, had been sleeping more, had not been eating well, had become more withdrawn, and requested additional services to assist for safety and health needs.
At issue is the medical necessity of Consumer Directed Personal Aide Service (CDPAS) 7 days x 7 hours.
The services are medically necessary. The patient had a documented increase in assistance needs. The patient is on insulin and requires assistance with checking her blood sugars and administering her insulin. The patient is on anticoagulant medication and at a higher risk for injury with any falls. The patient's son documented a decline in functional and cognitive status with need for increased assistance with tasks of eating, managing medication, meal preparation, transfer toilet, and toilet use. The telephonic assessment tool underestimated the patient's assistance needs with these tasks. The increase in CDPAP services is not solely for supervision and safety but to assist the patient with safe completion of instrumental activities of daily living (IADLs)/activities of daily living (ADLs). 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, CDPAS services 7 hours/day, 7days/week, to total 49 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.