Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Home Health Care. 

The insurer denied increase to temporary 84 hours per week consumer directed personal assistance services (CDPAS). 
The denial is overturned.

The patient is a female with past medical history of diabetes mellitus, diabetic neuropathy, coronary artery disease, hypertension, depression, gout, severe osteoarthritis, decubitus ulcer stage III, obesity, and urinary incontinence who had been assigned Consumer Directed Personal Assistance Program (CDPAP) for a total of 56 hours/week based on assessment tool performed assessing the patient at total assistance with tasks of ordinary housework while maximum assistance with task of meal preparation, stairs, shopping, and transportation. The patient was assessed at extensive assistance with tasks of managing finances, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, and toilet use while limited assistance with task of managing medication. With tasks of bed mobility and eating the patient was assessed as independent. The patient's primary care physician (PCP) provided a letter stating the patient's medical diagnoses, that her condition had deteriorated, that she had very poor eyesight, was unable to measure her blood pressure on her own, was at fall risk due to difficulty ambulating and unsteady gait, required constant assistance due to her clinical and mental status, had depression and anxious mood with low energy and difficulty in decision-making, needed assistance with house chores due to substantial fatigue and joint pain, needed assistance with meal preparation, personal care, feeding, and reminder for medication. Lastly, the PCP letter stated the patient would greatly benefit from home care services 12 hours/day, 7 days/week to stay safe and stable at home. The subject under review is the medical necessity for the temporary requested increase in hours.

The requested increase to temporary 84 hours per week CDPAS is medically necessary for this patient. There is documentation from the patient and the patient's PCP of a decline in physical and mental functioning. Furthermore, the assessment tool noted the patient's activities of daily living (ADL) status and overall self-sufficiency had declined and deteriorated. There was an increase in CDPAP assistance with tasks of stairs, bathing, dressing lower body, transfer toilet, toilet use, bed mobility, and eating. Although tasks of walking and locomotion did not occur the insurer did not estimate assistance needs for the patient which would have been extensive based on prior assessment. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's PCP has documented medical necessity of increase in home care services. 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 to temporary 84 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.