Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Consumer directed personal assistance program (CDPAP); 8 hours per day, 6 days per week for a total of 48 hours per week.
The insurer denied Consumer directed personal assistance program (CDPAP); 8 hours per day, 6 days per week for a total of 48 hours per week.
The determination is overturned.

The patient has a past medical history of dementia, urinary incontinence, chronic pain, diabetes mellitus type 2, hypothyroidism, hypertension, and gastroesophageal reflux disease (GERD) who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 5 hours/day, 6 days/week, to total 30 hours/week based on an assessment performed assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, bathing, dressing upper/lower body, walking, and locomotion. With the tasks of personal hygiene, transfer toilet, toilet use, and bed mobility the patient was assessed at limited assistance while supervision with tasks of managing finances, managing medication, and phone use. The patient was assessed at independent with the task of eating. The patient was hospitalized with pneumonia and there was a request to increase the personal care assistant (PCA) services and the patient underwent a video assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, stairs, bathing, and dressing upper/lower body. The patient was assessed at extensive assistance with tasks of phone use, transportation, walking, locomotion, transfer toilet, toilet use, and bed mobility while limited assistance with task of personal hygiene. With the task of eating, the patient was assessed as independent. Notes from the assessment noted a decline in activities of daily living (ADL) status in the last 90 days as well as a deterioration of overall self-sufficiency in the last 90 days. The insurer sent an initial adverse determination denial notice denying request to increase CDPAP services. The insurer sent a final adverse determination denial notice denying the request to increase CDPAP services stating the patient was able to direct her own care, the patient lived with her daughter and granddaughter who were supportive and involved in her care, the patient had needed adaptive equipment in the home, and time had been allotted for meal preparation, laundry, and housework. The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's diagnoses and that she required assistance with bathing, dressing, toileting, walking, and transferring. The provider also stated they supported the request to increase home care to 8 hours daily. The patient and her medical provider appealed the denial decision. At issue is the medical necessity of consumer directed personal assistance program (CDPAP); 8 hours per day, 6 days per week for a total of 48 hours per week.
The services are medically necessary. There is documentation of worsening cognitive and physical functioning following hospitalization for pneumonia. There is documentation from the patient's own medical provider of the medical necessity of increased home health aide services. The plan's assessment showed an increase in assistance needs with tasks of managing finances, managing medication, phone use, stairs, bathing, dressing upper/lower body, transfer toilet, toilet use, and bed mobility when compared to the prior assessment. With an increased need and assistance with tasks, specifically transfer toilet and toilet use, the patient would need assistance outside of the hours she has informal help. 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 (ADLs) and instrumental activities of daily living (IADLs). 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, 6 days/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.