Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizoaffective disorder, depressive type, Osteoarthritis.
Treatment: Consumer Directed Personal Assistance Program (CDPAP) services: 8 hours per day, 7 days per week- 56 hours per week. 
The insurer denied (CDPAP) services: Consumer Directed Personal Assistance Program 8 hours per day, 7 days per week- 56 hours per week. 
The determination is overturned.

The patient has a past medical history of depression, osteoarthritis, gastroesophageal reflux disease (GERD), anxiety, bipolar disorder, hyperlipidemia, and urinary incontinence who had been assigned Consumer Directed Personal Care Assistance Program (CDPAP) services 35 hours/week based on an assessment performed assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. With the tasks of managing medication, stairs, transportation, bathing, dressing lower body, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and bed mobility. The patient was assessed at set up only with tasks of managing finances and phone use while independent with task of eating. Notes from the assessment noted the patient had no informal helper. There was a request to increase CDPAP services and the patient underwent an assessment assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing medication, and shopping. The patient was assessed at extensive assistance with tasks of stairs, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use, and eating while limited assistance with tasks of personal hygiene, dressing upper body, and bed mobility.
Notes from the assessment stated the patient lived alone with her daughter in the upstairs apartment and the patient had a decline in activities of daily living (ADL) status and deterioration of overall self-sufficiency in the last 90 days. The assessment noted the patient had a child or child in law as informal support. The insurer sent an initial adverse determination denial notice denying request to increase CDPAP services. The denial noted the plan recommended social daycare which the patient declined and recommended durable medical equipment (DME) which the patient declined.
The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's medical diagnosis and request for more hours of home care to help patient have a better quality of life. The insurer sent final adverse determination denial notice denying request to increase CDPAP services stating the patient's personal care needs could continue to be met safely with current hours. In addition, the denial stated granting additional hours were not provided when tasks were not being performed and for safety monitoring and supervision.
The patient's psychologist provided a letter stating the patient was currently attending a counseling center for psychiatric treatment and individual psychotherapy. The patient's medications and diagnoses were also listed in the letter. The patient's daughter provided a letter stating the current hours were not sufficient to provide the patient with the services that she needs. In addition, the daughter's letter stated that she and her sister are currently caring for the patient 19 hours a day which is a a lot of work as they also have their own families to care for once they get home from their jobs. The daughter also noted the patient had psychiatric problems and on many occasions has tried to kill herself and has been hospitalized multiple times for suicide attempts and the daughter was afraid that she would try again when she was alone. In addition, the daughter noted they were trying to determine if the patient may have Huntington's disease as she has had involuntary movement, cognitive deterioration, and psychiatric symptoms. On the same date the patient/family appealed the denial decision. The patient's primary care physician (or provider) (PCP) requested an appeal of the denial decision.
At issue is the medical necessity of (CDPAP) services: 8 hours per day, 7 days per week- 56 hours per week. 

Yes, the services are medically necessary.
There is documentation from the patient's assessment of increased need of assistance with tasks of managing medication, walking, locomotion, and toilet use. The patient's primary care physician (or provider) (PCP) documents a medical necessity for increased hours. The patient's daughters serve as informal support and are not able to provide the same level of informal support as previous. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, CDPAP services 8 hours/day, 7 days/week, to total 56 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.