Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Increase for 56 hours per week Consumer Directed Personal Assistance Services (CDPAS).

The insurer denied the Increase for 56 hours per week Consumer Directed Personal Assistance Services (CDPAS).  The determination is overturned.

The patient has with a past medical history of dementia, vitamin D deficiency, urinary incontinence, coronary artery disease, hypertension, hyperlipidemia, atrial fibrillation, osteoarthritis, and diabetes mellitus type 2 who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 28 hours/week based on an assessment tool performed assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, stairs, shopping, and transportation while extensive assistance with tasks of managing finances, managing medication, phone use, bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, and eating while independent with bed mobility.

There was a request to increase CDPAP services and the patient underwent another assessment tool via facetime assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, phone use, stairs, and shopping while maximum assistance with tasks of managing medication, transportation, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility while limited assistance with task of eating. The notes from this assessment stated the patient utilized a cane/rolling walker for ambulation, was moderately impaired cognitively, and the patient's husband was in the hospital. In addition, the notes from this assessment stated the patient had functional decline with muscle weakness, has difficulty bearing weight with ability to walk only a couple of feet with wheeled walker and one person underarm assistance, was wheeled by others for longer distances, needed assistance with toileting and toilet transfers, and required hands on assistance with positional changes. The insurer sent an initial adverse determination denial notice stating the denial to increase CDPAP services. The denial further stated that the patient lived with her son who is supportive and able to help with her care, had a small change in physical status, and the patient had a walker and was able to walk with assistance.

The patient had a house call with her primary care physician (PCP) noting the patient was verbally responsive but confused, had worsening ability to walk, has pain in multiple joints, and was getting physical therapy (PT) with some effect. The house call provider told the family to turn and reposition the patient at least every 2 hours to promote circulation and prevent skin breakdown. The plan sent a final adverse denial determination notice stating the request to increase CDPAP services was not medically necessary but there was partial approval of CDPAP services 42 hours/week. The denial stated the need for daily activities was unchanged and the plan did not provide hours for safety and supervision. On an unknown date, the patient's cardiologist provided a letter requesting an increase in person care services as medically necessary to meet all of the patient's personal care needs. The note further stated the patient requires an aide for all bathroom trips and needs total assistance with walking and transferring.

The patient's health care advocate provided a letter requesting external appeal on behalf of the patient noting the patient lives with her two sons, one of whom is disabled and in a wheelchair, but makes financial decision for her, and another son who is her CDPAP. The son who is CDPAP is unable to devote more time to care for the patient due to his own medical conditions and need to care for his son and the family would request a second aide to assist with the patient's care. The letter further stated the patient had been hospitalized with shortness of breath and found to have pulmonary embolism and was positive for Covid antibodies. Since this hospitalization the patient had worsening muscle weakness and now required a wheelchair for ambulation and required total assistance with transfers. The plan send a case summary summarizing the patient's assessments and the plan's decisions for CDPAP coverage. At issue is the medical necessity of an increase for 56 hours per week Consumer Directed Personal Assistance Services (CDPAS).

Yes, the services are medically necessary.

The patient has a documented decline in her functional status based on the Uniform Assessment System (UAS) when compared to the prior assessment. The patient has since been hospitalized following her last assessment with further decline in her functional status as outlined in the healthcare advocate letter. The patient's son is not able to provide more care for the patient given his own medical problems. The patient has unscheduled and unpredictable care needs over a continuum of time and the insurer failed to document a plan to meet these needs. The requested increase in CDPAP/personal care assistant (PCA) hours are not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)/ Instrumental activities of daily living (IADL) tasks. 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, CDPAS/PCA services 56 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.