Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fibromyalgia, Osteoarthritis, Cervical radiculopathy, Neuropathy, Systemic lupus erythematosus (SLE).

Treatment: Consumer Directed Personal Care Services (CDPAS), per 15 minutes, 32 Hour(s) per week.

The insurer denied coverage for Consumer Directed Personal Care Services (CDPAS), per 15 minutes, 32 Hour(s) per week.

The denial is overturned.

This is a female patient who has various medical conditions associated with symptoms affecting her functional ability to perform daily activities. The patient lives alone and has been receiving consumer directed personal assistance services (CDPAS) 4 days per week, total of 20 hours per week. A request was made to increase CDPAS to 32 hours per week which was denied. 
The patient has several medical conditions that can have significant effects on daily function, including fibromyalgia, systemic lupus erythematosus (SLE), osteoarthritis, cervical radiculopathy, and neuropathy. The patient was also diagnosed with biceps tendonitis. A physician reports that the patient has chronic back and shoulder pain, and difficulty walking. Fibromyalgia and SLE can co-exist and some symptoms are similar, such as: joint pain, fatigue, memory impairment, depression; however, they are different clinical entities. SLE is a systemic autoimmune disease. Fibromyalgia is chronic pain syndrome. The patient also has cervical radiculopathy which can cause pain, sensory deficits and motor dysfunction in the upper extremities. A diagnosis of biceps tendinitis causes shoulder and upper arm pain. The patient's functional ability for daily activities is the cumulative effect of these various conditions, with symptoms that may fluctuate in frequency and severity.
Symptoms noted in Uniform Assessment System (UAS) reports includes joint pain, muscle cramps and spasms, left arm weakness, poor endurance, poor balance, and unsteady gait. Functional assessment in a UAS report indicated that the patient needed maximal assistance for housekeeping tasks and shopping. She needed extensive assistance with meal preparation, stairs and transportation. An assessment of activities of daily living (ADLs) revealed that the patient could complete most activities independently with set up help; except bathing (independent with no setup help); lower body dressing (extensive assistance); toilet use (limited assistance). The patient's daughter (as patient's designee) noted her mother is unable to lift things or hold onto things for an extended period of time. She has dropped pots of food causing burns. She has difficulty raising her arms (causes severe pain). She has had multiple falls and is afraid to go outside alone due to fear of falling. She has memory impairment; often forgetting things and losing things.
Considering the patient's medical history, chronic symptoms and need for assistance with multiple daily activities, it is medically necessary for the patient to have assistance with instrumental activities of daily living (IADLs) and ADLs on a daily basis to help prevent falls and other household accidents; and ensure the patient can complete daily tasks properly and safely. Using the additional 12 hours for the other 3 days of the week will provide time for ADLs that need daily assistance (bathing, personal hygiene, dressing, toileting), provide the patient with assistance for mobility around the house, and enable her to go outside of her home any day of the week with assistance. Meal preparation can be done daily, and assistance with housekeeping tasks can be managed each day as needed, so that the patient can minimize situations when she needs to attend to household activities unassisted.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for CDPAS, per 15 minutes, 32 Hour(s) per week is overturned. The medical necessity is substantiated.