Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, sleep apnea, stroke

Treatment: Home Health Care (live-in)

The insurer denied coverage for Home Health Care (live-in)

The denial is overturned

 
This case involves an elderly patient with a subject for review for the Denial of coverage for Consumer Directed Personal Assistance Program (CDPAP): Live-In Per Diem- 1 day (24 hours)- 7 days per week a total of 7 days per week.

Upon review of the Uniform Assessment System Comprehensive Community Health Assessment Report, it was noted that the patient has a significant decline in her functioning. Assessment showed that the patient requires Maximal assistance with meal preparation, managing finances, managing medications; Totally dependent with ordinary housework, locomotion; Extensive assistance with bathing, dressing the lower body, toilet use; Limited assistance with personal hygiene, dressing the upper body, walking, transfer to toilet, bed mobility; Independent with eating and set up help with phone use. The assessment determined that the patient requires Maximal assistance with meal preparation, managing finances, managing medications, shopping, personal hygiene, dressing the upper body, bed mobility, eating; Totally dependent with ordinary housework, transportation, bathing, dressing the lower body, walking, locomotion, toilet use; and Limited assistance with phone use. 

Per the assessment, it was determined that the patient requires assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) due to increased pain, joint stiffness related to worsening osteoarthritis (OA), cramps/numbness of fingers, hands, arms, shoulders, and legs. She is unable to bend and close her hands and fingers, she also has left sided weakness (hemiparesis) due to cerebrovascular accident (CVA), nerve damage from the diagnosis of Rhabdomyolysis, dizziness, fatigue, and increased weakness. She also is unable to stand and walk. In addition, the patient has not used toilet commode and her bladder and bowel movement are done while on bed. She is frequently incontinent with bladder and occasionally incontinent with bowel. Dyspnea is absent at rest, but present when performing moderate activities. During the assessment it was also noted that the patient's overall self-sufficiency has significantly declined after the stroke and hospitalization. She has severe pain in her major joints, stiffness, loss of strength and increased weakness.  

Due to her frequent falls, significant decline in her cognitive and physical functioning, dizziness, fatigue, and increased weakness, and incontinence, the Consumer Directed Personal Assistance Program (CDPAP): Live-In Per Diem- 1 day (24 hours)- 7 days per week a total of 7 days per week will help the patient to be safe and to achieve her needs to complete her ADLs and IADLs. The Consumer Directed Personal Assistance Program (CDPAP) is a program that provides services to chronically ill or physically disabled individuals who have a medical need for help with activities of daily living (ADLs) or skilled nursing services. In this case, the participant is physically disabled as noted in the assessments and Emergency Room visits due to her frequent falls. Therefore, the Denial of coverage for Consumer Directed Personal Assistance Program (CDPAP): Live-In Per Diem- 1 day(24 hours)- 7 days per week a total of 7 days per week is overturned.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Assistance Program (CDPAP): Live-In Per Diem- 1 day- 7 days per week- a total of 7 days per week services is substantiated.