Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Congestive heart failure, COPD (Chronic obstructive pulmonary disease) and essential tremor.
Treatment:  Consumer directed personal assistance services (CDPAS) 24 hours a day, 7 days a week (continuous care by more than 1 person), totaling 168 hours per week.

The insurer denied coverage for Consumer directed personal assistance services (CDPAS) 24 hours a day, 7 days a week (continuous care by more than 1 person), totaling 168 hours per week.  The denial is upheld.

This is an elderly adult with congestive heart failure, COPD (Chronic obstructive pulmonary disease) and essential tremor. The patient lives alone in a private residence. The insurer approved consumer directed personal assistance services (CDPAS) 24 hours/day, 7 days/week (live-in); 91 hours per week and the request is for CDPAS 24 hours a day, 7 days a week (continuous care by more than 1 person), totaling 168 hours per week.

The Uniform Assessment System (UAS), was reviewed. The Patient's cognition is described as minimally impaired. The patient is totally dependent to maximal assistance for completing much of the Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is reportedly total dependent for personal hygiene. Maximal assistance is needed for bathing, dressing, bed mobility ("member sleeps on a couch bed"), eating and toilet use. Extensive assistance is needed for toilet transfer, locomotion and ambulation. The patient also requires extensive assistance for placing portable oxygen via nasal cannula. The patient is frequently incontinent of bladder and infrequently incontinent of bowel. There was 1 fall in January 2023, with no injury reported. The patient's cognition has declined (modified independent to minimally impaired) when compared to previous UAS. 

The letters from the patient's treating physician and son, respectively describing the patient's clinical condition and functional needs were reviewed. The letters do not describe a level of care, medical condition and functional incapacity that requires the requested CDPAS 24 hours a day, 7 days a week (continuous care by more than one person), totaling 168 hours per week. This physician would also agree that the patient may benefit from additional monitoring; particularly due to her reported cognitive decline, tremor and falls risk. However, safety monitoring under personal care services (PCS) does not include monitoring an individual (e.g., with dementia, falls risk, general weakness) when no other Level I or Level II personal care services task is being provided. Based on the clinical records, the approved live-in CDPAS is likely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. Based on the enclosed documents reviewed, the patient's health and safety is appropriately provided and maintained at home with the approved CDPAS 7 days a week live-in services - 91 hours.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, CDPAS 24 hours a day, continuous care by more than one person, totaling 168 hours per week is not medically necessary.    

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an increase in consumer directed personal assistance services (CDPAS) to 24 hours per day, continuous care by more than one person, 168 hours per week is not substantiated.