Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraines
Treatment: consumer directed personal assistance program (CDPAP): 6.5 hours per day-7 days per week- a total of 45.5 hours per week hours per week
The insurer denied consumer directed personal assistance program (CDPAP): 6.5 hours per day-7 days per week- a total of 45.5 hours per week hours per week.
The determination is overturned.

This is a female patient with a past medical history of osteoarthritis, chronic neck pain, chronic back pain, hyperlipidemia, neuralgia, and migraines who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 4.5 hours/day, 4 days per week and 6.5 hours, 1 day a week to total 24.5 hours/week based on video assessment. There was a request to increase CDPAP services and the patient underwent another video assessment  
The insurer sent an initial adverse determination denial notice denying the request to increase CDPAP services recommending physical therapy which the patient agreed to, recommended follow-up with pain management which the patient stated she had already done, recommended a personal emergency response system (PERS) which she declined, and recommended an evaluation for durable medical equipment (DME) which the patient declined. The denial also stated the current hours were appropriately and safely meeting the patient's personal care needs. The insurer continued to deny the request to increase CDPAP services stating the patient lived with her sister and brother who were supportive in her care and based on the recent assessment, the patient's personal care needs could continue to be met safely with the current hours. The denial stated additional hours were not provided when tasks were not being performed and therefore, an increase in services was not medically necessary. The patient's primary care physician (or provider) (PCP) provided a letter stating the patient has a diagnosis of migraines which had become severe over time and the patient needed extra assistance to help with her daily routine due to her worsened condition and it was recommended the patient receive extra assistance. At issue is the medical necessity of consumer directed personal assistance program (CDPAP): 6.5 hours per day-7 days per week- a total of 45.5 hours per week hours per week.

Yes, the services are medically necessary. There is documentation from the patient's medical provider of a need for increased assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The plan's own assessment showed an increase in assistance needs with tasks of ordinary housework, phone use, transportation, personal hygiene, dressing upper body, and bed mobility when comparing the recent assessment to the prior assessment. The plan assumed the patient had informal support outside of currently assigned CDPAP services. The patient requests at least limited assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and 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 6.5 hours/day, 7 days/week, to total 45.5 hours/week are medically necessary for this patient.