Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizoaffective disorder, bipolar type. 

Treatment: Increase consumer directed personal assistance services (CDPAS) from 18 hours to 56 hours per week. 

The insurer denied coverage for an increase in consumer directed personal assistance services (CDPAS) from 18 hours to 56 hours per week. 

The denial is upheld. 

This is a male patient with a diagnosis of schizoaffective disorder, bipolar type. The patient reportedly had a history of auditory hallucinations, responding to internal stimuli, and delusional thinking. The patient was treated with Invega Sustenna intramuscular (IM) injections 234 mg every 4 weeks and was seen by his psychiatrist for monthly treatments. The patient was prescribed Seroquel, Fanapt, and Lamictal in addition to the Invega Sustenna IM injections. The request was for an increase in consumer directed personal assistance services (CDPAS) from the approved 18 hours per week to 56 hours per week. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that the least restrictive level of care for safe and effective treatment is appropriate. The Department of Health reports that personal care services (PCS) helps people with everyday tasks including activities of daily living (ADL's) or household tasks. It also states that personal care attends to the physical needs of people disabled or otherwise unable to take care of themselves. Such ADL's include bathing, showering, management of bodily fluids, toileting, feeding, ambulating, transferring from bed to chair or wheelchair, or in and out of the tub or shower, grooming, taking care of teeth or mouth, housekeeping, or meal preparation. 

In this case, this patient did not have an increase in reported difficulties bathing, showering, management of bodily fluids, toileting, feeding, ambulating, grooming, taking care of teeth or mouth, housekeeping, or meal preparation that warranted more than the provided and approved 18 hours per week of CDPAS. It was reported that when paranoid, the patient feels lost without an escort and isolates more but he reportedly was in treatment with his psychiatrist and was on the treatment of choice for his psychotic symptoms according to the APA Practice Guidelines for the Treatment of Patients with Schizophrenia. The literature supports that if the patient experiences more psychotic symptoms such as paranoid delusional thinking, the standard treatment would be to increase his antipsychotic medication. The patient reportedly was taking Invega Sustenna every 4 weeks. Documentation showed that the patient was emotionally good with better behavioral control, denied hallucinations or delusional thinking or bizarre thoughts, and was sleeping and eating well, and was compliant with appropriate behavior in multiple settings. 

Based on the patient's medical record, there is lack of specific evidence to support that an increase in weekly CDPAS from 18 hours to 56 hours per week was the least restrictive medically necessary service for this patient. As a result, the requested increase in CDPAS is not considered medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for CDPAS 56 hours per week should be upheld. The medical necessity is not substantiated.