Appeal type: Medical necessity
Decision: Upheld


 
Diagnosis: Chronic Obstructive Pulmonary Disease

Treatment: Consumer and self-directed personal assistance services (CDPAS), 75 hours per week

The insurer denied coverage for consumer and self-directed personal assistance services (CDPAS), 75 hours per week

The denial is upheld 

This is a patient with chronic medical problems including chronic obstructive pulmonary disease (COPD) (with home oxygen), fibromyalgia and post-polio syndrome. The patient lives with their daughter in a private residence and has a supportive family. The patient is currently approved for 56 Consumer Directed Personal Assistance Program (CDPAS) hours/week and the request is for 75 hours/week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is modified independent. The patient "is able to direct care and make decisions on her healthcare needs. The patient is able to contact 911 and activate personal emergency response system (PERS) in the event of an emergency." The patient is reportedly total dependent to maximal assistance for performing Instrumental Activities of Daily Living (IADL) tasks including shopping, ordinary housework and meal preparation. The patient is also reportedly total dependent for locomotion with a motorized wheelchair as their primary mode of mobility. Maximal assistance is reportedly needed for bathing, lower body dressing, toilet transfer/use. Extensive assistance is reportedly needed for upper body dressing and bed mobility. Limited assistance is reportedly needed for eating. The patient reports being frequently incontinent of bladder and infrequently incontinent of bowel. 

The patient reports that their self-sufficiency and activities of daily living (ADL) status have deteriorated and declined, respectively over the prior 90 days. There have been no reported falls over the prior 90 days. The letter from the patient's treating physician assistant (PA) was reviewed. The PA describes the patient's underlying medical conditions, associated impairments and necessary time for care/services. However, there are no submitted treatment notes or evidence of specific clinical/functional decline; particularly since they moved in with their daughter. This physician would agree the patient may actually require additional supervision and monitoring. However, safety monitoring under CDPAS does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently 56 CDPAS hours/week, shared household responsibilities of the other adult living in the home, informal care from family and Personal Emergency Response System (PERS). 

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, as well as within a reasonable degree of medical certainty, the requested consumer and self-directed personal assistance services (CDPAS), 75 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 consumer and self-directed personal assistance services (CDPAS), 75 hours per week is not substantiated.