Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall Risk
Treatment: Consumer directed personal assistance (CDPAP) 9 hours per day, 7 days a week- total of 63 hours per week.
The insurer denied consumer directed personal assistance (CDPAP) 9 hours per day, 7 days a week- total of 63 hours per week.
The determination is overturned.

The patient has a past medical history of diabetes mellitus type 2, diabetic neuropathy, benign prostatic hyperplasia (BPH), urinary incontinence, lumbar disc degeneration, mild cognitive impairment, osteoarthritis, and gastroesophageal reflux disease (GERD) who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 5 hours/day, 7 days/week, to total 35 hours/week based on an assessment assessing the patient at total assistance with the task of ordinary housework while maximum assistance with the tasks of meal preparation, stairs, shopping, and transportation. With the tasks of bathing, dressing lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with the tasks of personal hygiene, dressing upper body, and bed mobility. The patient was assessed at supervision with the task of managing medication, set up with tasks of managing finances and phone use, while independent with the task of eating.
There was a request to increase CDPAP services and the patient underwent another assessment assessing the patient at the same level for all tasks when compared to the prior assessment. The insurer sent an initial adverse determination denial notice denying request to increase CDPAP services stating the service was not medically necessary. the insurer sent a final adverse determination denial notice continuing to deny an increase in CDPAP services stating his ability to perform daily activities remained the same when comparing the 2 assessments, he was able to direct his own care, his daughter was supportive and involved in his care, he was able to activate a personal emergency response system in case of an emergency, he had durable medical equipment (DME) within the home, and granting additional hours were not provided when the tasks were not being performed and for safety monitoring and supervision. The patient appealed the denial decision. The patient's primary care physician (or provider) (PCP) provided a letter stating they were writing on behalf of the patient to document the medical necessity of an increased number of home health hours and to ensure continuation of care. The provider noted the patient's aide was currently working with him from 9 AM to 2 PM, 7 days/week, however, the patient required assistance during the evening with numerous activities of daily living and assistance due to a recent increase in falls.
At issue is the medical necessity of consumer directed personal assistance (CDPAP) 9 hours per day, 7 days a week- total of 63 hours per week.
The services are medically necessary.
There is documentation from the patient's primary care provider of medical necessity for increased CDPAP services. The insurer incorrectly assumed the patient had informal help outside of all of the hours of currently assigned CDPAP services. The patient requires extensive assistance with walking, locomotion, transfer toilet, and toilet use which are unpredictable and unscheduled care needs that span a continuum of time. The insurer did not document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). 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, CDPAP services 9 hours/day, 7 days/week, to total 63 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 his own home.