Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis

Treatment: Consumer Directed Personal Assistance Program (CDPAP): 4 hours per day, 7 days per week, a total of 28 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP): 4 hours per day, 7 days per week, a total of 28 hours per week

The denial is overturned.

The patient is seeking coverage for Consumer Directed Personal Assistance Program (CDPAP); 4 hours per day, 7 days per week, a total of 28 hours per week.  The patient was diagnosed with unspecified osteoarthritis of unspecified site and primary generalized osteoarthritis.

The patient underwent a reassessment due to significant change. The patient had modified independence for cognitive skills for daily decision making. There was some difficulty in new situations only. The patient had short-term memory problems. There was no change in decision making as compared to 90 days prior. The patient was alert and oriented x 3 with occasional forgetfulness. The patient was able to recall 1 out of 3 words in 5 minutes. The patient's hearing and vision were adequate. The patient required maximal assistance with meal preparation, total dependence with ordinary housework, maximal assistance with managing finances, limited assistance with telephone use, extensive assistance with stairs, maximal assistance with shopping, extensive assistance with transportation, extensive assistance with bathing, limited assistance with personal hygiene, limited assistance with dressing of the upper body, extensive assistance with dressing of the lower body, limited assistance with walking, extensive assistance with toilet transfer, and limited assistance with toilet use.  The patient required supervision with oversight/cueing for bed mobility.  The patient was independent with set up help only for eating.  The patient needed assistance due to arthritis.  The patient's health condition caused pain/stiffness, loss of range of motion, and unsteadiness.  The patient reported a decline in activities of daily living and self-sufficiency in the last 90 days due to progression of osteoarthritis that caused increased pain and stiffness as well as unsteadiness.  The patient required some weightbearing assistance for bathing.  The patient was occasionally incontinent of bladder and continent of bowel.  The client task sheet estimated that the patient needed 4.5 hours of assistance per day for a total of 31.5 hours.

The clinical review checklist from reported that the patient needed limited assistance with dressing of the upper body (prior independent with set up help only), limited assistance with personal hygiene (prior independent), extensive assistance with dressing of the lower body (prior limited assistance), limited assistance with toilet use (prior independent), extensive assistance for toilet transfer (prior supervision), extensive assistance for bathing (prior supervision), limited assistance for walking (prior independent), limited assistance for locomotion (prior independent), and supervision with bed mobility (prior independent).  The patient requested an increase in services as they were unable to complete tasks due to pain and weakness.  The patient lived with a spouse, son, and daughter-in-law.  The patient's son and daughter-in-law were supportive.  The patient had a walker, shower chair, shower grab bar, and cane to assist with needs at home.  Outpatient physical therapy was discussed, which the patient declined.  Restructuring of the current hours was discussed and declined.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Assistance Program (CDPAP): 4 hours per day, 7 days per week, a total of 28 hours per week is substantiated.