Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, legal blindness, and glaucoma

Treatment is directed personal assistance program (CDPAP): 8 hours per day - 7 days per week - for a total of 56 hours per week

The insurer denied coverage for directed personal assistance program (CDPAP): 8 hours per day - 7 days per week - for a total of 56 hours per week
 
The denial is overturned

This patient has experienced functional decline over the past year related to various medical conditions. She lives with her daughter and son-in-law. She has been receiving personal care services, provided through a Consumer Directed Personal Assistance Program (CDPAP) 8 hours per day, 5 days per week, for a total of 40 hours per week. As per UAS (uniform assessment system), she also receives some informal help from her daughter. A request was made to increase CDPAP services to 8 hours per day, 7 days per week, total of 56 hours per week, which was denied. An external appeal was requested. 

The most recent UAS provided was reviewed. The functional status report for IADLs (instrumental activities of daily living) indicates the patient is totally dependent for ordinary housework and managing finances; she needs maximal assistance for meal preparation, managing medications, shopping, stairs; extensive assistance for phone use, transportation. For ADLs (activities of daily living), the patient needs maximal assistance for bathing, dressing lower body; extensive assistance for personal hygiene, dressing upper body, walking, locomotion, transferring to the toilet, toilet use, bed mobility; and supervision for eating.          

The patient has significant vision and hearing loss; progressive cognitive decline; weakness and severe fatigue. She has physical limitations including unsteady gait, difficulty with transfers, and decreased ROM (range of motion). The combined effect of these problems in an elderly person is physically and mentally stressful and can be overwhelming. Caregiver assistance is necessary for proper and safe completion of all daily activities and to help relieve some of the burden and anxiety of performing daily tasks.

The patient's care needs extend throughout the day, and probably at night (e.g., nighttime toileting). The patient (via designee) requested CDPAP 56 hours per week, 8 hours per day, 7 days per week. Considering the patient's functional decline over the past year and high level of care needed for daily activities, CDPAP 56 hour per week is a more realistic plan. The additional hours per week can better accommodate the patient's daily care needs 7 days per week when help is needed for routine, unscheduled and recurring activities.

Based on the information provided for review, it is medically necessary to increase personal care services (in this case CDPAP) due to the patient's
physical and cognitive decline, her need for weightbearing assistance for most ADLs, and her need for assistance with all routine, and unscheduled and/or recurring care needs during the day and night, 7 days per week.

Recommendation is given to approve Consumer Directed Personal Assistance Program services, 8 hours per day, 7 days per week, total of 56 hours per week.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the consumer directed personal assistance program (CDPAP): 8 hours per day - 7 days per week - for a total of 56 hours per week is overturned. Medical Necessity is substantiated.