Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health Issues
Treatment: Increase in Consumer Directed Personal 
Assistance (CDPAP) for a Total of 56 Hours per Week
The insurer denied: Increase in Consumer Directed Personal 
Assistance (CDPAP) for a Total of 56 Hours per Week
The denial is overturned.

The patient is an adult female who appealed for an increase in Consumer Directed Personal Assistance (CDPAP) for a total of 56 hours per week (through her son). A review of the Health Plan indicates that the patient is approved for a total of 12 hours per week. Several months ago, the Health Plan wrote: "...we decided we are not changing our decision to deny your request for an increase in CDPAP services." The patient's primary care physician and psychiatrist have written letters of support. A few months ago, the attending provider from psychiatry wrote: "I am writing this letter on behalf of [the patient] who has been under my care... She follows her appointments monthly. She carries the diagnoses of: Psychosis Disorder Unspecified - Post Traumatic 
Stress Disorder- Anxiety Disorder Unspecified. Her clinical conditions have fluctuated i.e., having good and bad days. She described her symptoms as follows: Pejorative and command Auditory Hallucinations ('You're not good -You would better be dead than alive -Leave the house and go to the streets - shave your hair). She eventually followed the voice's suggestions and was finally hospitalized in a psychiatric unit. Her condition has improved being she still has some residual symptoms i.e., she is still paranoid (fear of being alone, the tendency to follow the 
voices when she hears them - insomnia - some occasional panic attacks, etc.). Her current psychotropic medications are Risperdal, Duloxetine, Trazodone, and Klonopin. Her primary care physician wrote: "The patient has been diagnosed with 
Major depressive disorder, Hypothyroidism, Hypertension, Hyperlipidemia, and Prediabetes. The patient is under the care of an aide for 3 hours a day. [The patient] is illiterate, which makes it harder for her to know the order of her medications, The patient's aide assists the patient with showering and dressing her, with meal preparation medications, doctor visits, and all daily 
living activities. Due to the patient's condition, as the primary care physician I am requesting this patient to be taken into consideration to approve as many hours of home care as possible. [The patient] needs someone with her most hours of the day as per the psychiatrist's concern as well."

The requested health service is medically necessary.

A review of the providers' letters of support as well as the son's letter indicates that, given the patient's illiteracy and mental health issues with psychotic features, she is unable to comply with her medication treatment reliably and safely. This non-compliance can only worsen her mental health status as well as worsen her physical illnesses, including but not limited to worsening hypothyroidism and hypertension. Her healthcare proxy notes there is a limited amount of help that he and his family can provide (as outlined in his letter). Thus, it is reasonable based on clinical rationale that the patient needs additional help up to 56 hours per week.