Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Coronary Artery Disease

Treatment: Consumer Directed Personal Assistance Services (CDPAS), 7 hours a day, 7 days a week, a total of 49 hours a week

The insurer is denied coverage for Consumer Directed Personal Assistance Services (CDPAS), 7 hours a day, 7 days a week, a total of 49 hours a week

The denial is overturned.
This is a female patient who lives at home with daughter. The patient has a history of coronary heart disease, atrial fibrillation, hypertension, hyperlipidemia, mild cognitive impairment, functional urinary incontinence, overactive bladder, fecal urgency, osteoarthritis, pain, difficulty walking, unsteadiness on feet, cataract extraction right eye, glaucoma, vit B and D deficiency that has substantial functional impairment and needs assistance for all household tasks, mobility and self-care activities. The patient is approved for consumer directed personal assistance services (CDPAS), 7 hours per day, 5 days per week; 35 hours per week.

The patient needs assistance for all transfers and ambulation. Although the patient's out of bed activity is limited, assistance is needed at various times of the day to help the patient transfer in and out of bed or a chair, and take a few steps. The patient is incontinent but it appears she also still uses the toilet (extensive assistance for transfer toilet and toilet use). The patient has multiple risk factors for falls, including: arthritis, pain, unsteady gait, advanced age, incontinence, cognitive impairment, use of medications associated with falls (e.g. antihypertensive drugs, tramadol). The patient is also taking Coumadin; which increases risk of significant bleeding in the event of a fall; especially hemorrhagic complications of head trauma. When elderly people fall, there is higher risk of serious injury, associated with substantial morbidity and increased risk of death. The UAS indicates no recent falls. Having caregiver assistance for mobility related ADLs has most likely been a useful intervention to prevent falls.

In addition to the need for caregiver assistance with mobility related ADLs (transfer, walking, toileting) that occur throughout the day, the patient needs daily assistance for other personal care activities (bathing, dressing, personal hygiene). She needs daily meal preparation and service for all meals, and assistance with some other IADLs (e.g. medications, some housekeeping chores). The request for additional CDPAS hours is not to increase current daily hours, but to add Saturday and Sunday. The patient's need for assistance with daily activities on Saturday and Sunday is the same as Monday through Friday; and so the reason for denial of CDPAS hours for weekends is not clear. The insurer's final denial letter states those CDPAS hours are flexible and can be used throughout the day to meet the patient's personal care needs. It is not clear whether the insurer may be suggesting that the 35 hours approved for 5 days per week should be allocated over 7 days. The patient needs a high level of assistance for ADLs and IADLs; and assistance for toileting is needed throughout the day; and so 35 hours per week over 7 days per week, i.e. less hours per day, would not be an adequate plan.

Consumer Directed Personal Assistance Services 7 hours per day, 7 days per week, total of 49 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Consumer Directed Personal Assistance
Services (CDPAS), 7 hours a day, 7 days a week, and a total of 49 hours a week is substantiated. The insurer's denial is overturned.