Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatic Cancer; End Stage Renal Disease; Interstitial Lung Disease. 
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services. 

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP) Services at 12 hours per day, 7 days a week for a total of 84 hours per week. 

The denial is overturned. 

This male patient has a past medical history of osteoarthritis, anemia, lumbar spondylosis, spinal stenosis of the lumbar region, lumbar radiculopathy, mixed hyperlipidemia, type 2 diabetes mellitus, pancreatic cancer, end stage renal disease and interstitial lung disease. The patient is totally dependent for meal preparation, ordinary housework, managing finances, managing medications, shopping and bathing. He needs maximum assistance with transportation, personal hygiene, dressing, walking, toileting, and bed mobility. He uses an assistive device for locomotion indoors. The patient requires assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs).  He receives consumer directed personal assistance program (CDPAP) services 56 hours per week (8 hours per day, 7 days per week). The plan initially approved CDPAP 7 hours per day, 7 days per week; total of 49 hours per week. CDPAP 12 hours per day, 7 days per week; total of 84 hours per week has been requested. 

The patient lives with his wife who is unable to provide informal support to the patient due to her own medical conditions. He needs assistance with all activities of daily living which occur on a frequent basis, including scheduled and unscheduled care needs. The current schedule leaves the patient without assistance after the CDPAP aide shift ends. 

The patient's physician submitted a letter of medical necessity which includes the following: The patient's condition has deteriorated in the last 6 months. The patient now has end stage renal disease requiring dialysis; interstitial lung disease with shortness of breath, brittle diabetes (insulin dependent), severe low back pain due to lumbar spondylosis, making mobility difficult. The patient would benefit from more hours. 

The most recent Uniform assessment System (UAS) indicated he was totally dependent for most IADLs, except stairs and transportation (maximal assistance) and phone use (setup help). The patient needed maximal assistance for all ADLs, except bathing (total dependence), and eating (extensive assistance). 

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple chronic medical conditions. Pain, dyspnea and fatigue are debilitating symptoms. When they occur together, this is a substantial obstacle to daily function. The total symptom burden for an elderly patient can be overwhelming, and results in declining physical function and increasing dependence on caregivers for daily activities. 

It is necessary to support his nutritional intake and physician office notes indicated episodes of hypoglycemia. The patient's mobility is severely impaired. He patient needs maximal assistance for toilet transfer and toilet use. He has impaired bed mobility. He has no effective means of relieving pain without assistance. Considering the patient's medical history and functional status, it is medically necessary for the patient to have a caregiver present throughout the day to assist with all daily activities. Sufficient time for caregiver assistance should be provided so the patient does not need to remain in bed up to 16 hours per day. 

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

Based on the above, the medical necessity for Consumer Directed Personal Assistance Program (CDPAP) Services at 12 hours per day, 7 days a week for a total of 84 hours per week is substantiated. The insurer's denial should be overturned.