Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Home Health care-Personal Care Aid
The health plan denied the increase in CDPAP hours as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient has a past medical history of osteoarthritis, rheumatoid arthritis, osteoporosis, wheelchair-bound status, urinary incontinence, hypertension, hyperlipidemia, congestive heart failure, coronary artery disease, chronic kidney disease, and spinal stenosis who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 6 hours/day, 7 days/week, to total 42 hours/week based on assessment tool performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, and locomotion while maximum assistance with tasks of shopping, transportation, bathing, dressing lower body, walking, and transfer toilet. With tasks of personal hygiene, dressing upper body, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of managing finances, managing medication, phone use, bed mobility, and eating. Notes from the assessment stated the patient's health conditions caused pain, fatigue, and shortness of breath. The notes also stated the patient required significant weightbearing assistance with walking and when transferring to and from toilet. In addition, the notes from the assessment stated the patient required some weightbearing assistance when using the toilet to clean and wipe self or when changing incontinence supplies. The patient saw her primary care physician (PCP) with office note stating the patient was wheelchair-bound due to osteoarthritis of the hip. The patient had falls with resultant head injuries caused by these falls. Both falls occurred when the patient was without assistance. There was a request to increase CDPAP services and the patient underwent a telephonic assessment tool.

The requested increase in CDPAP services is medically necessary for this patient. The patient lives alone and requires assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient has chronic progressive medical conditions of osteoarthritis, rheumatoid arthritis, spinal stenosis, and is wheelchair-bound. The patient has unpredictable and unscheduled care needs that span a continuum of time and no plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met with current CDPAP service hours and/or adaptive equipment and/or medical supplies. The requested increase in CDPAP services is not solely for safety and supervision, but to assist the patient with safe completion of ADLs/IADLs. Taking into account clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 24 hours/day, live-in, 7 days/week, to total 168 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.