Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Home Health Care- Personal Care Assistant. 
The insurer denied a home health care increase for medical necessity. 
The denial was overturned. 

The patient is a female with a past medical history of hypertension, osteoporosis, depression, diabetes mellitus type 2, glaucoma, gastroesophageal reflux disease (GERD), dementia, and urinary incontinence who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 7-1/2 hours per day, 7 days per week. 

There was a request to increase CDPAP services to 12 hours/day, 7 days/week, to total 84 hours/week. The health plan sent final adverse determination denial denying request to increase CDPAP services stating the increase was not medically necessary. The letter stated the request was made because the patient's daughter felt the patient needed additional assistance with going to the bathroom, making dinner, and going to bed. In the denial notice the plan outlined the medical equipment which the patient had in her home (cane, shower chair, shower grab bar, walker, and incontinence supplies). The denial also stated they are unable to grant additional hours when tasks are not being performed and for safety monitoring and supervision.

The patient's primary care physician provided a letter stating the patient requires assistance with activities of daily living (ADLs) on an ongoing basis due to her chronic and debilitating conditions and the patient's family cannot support the patient after her home health aide leaves as the patient needs continuous assistance. The letter stated the patient has 24-hour care needs and should have two, 12-hour shift attendants. 

At issue is the medical necessity of an Increase in Consumer Directed Personal Assistance Program (CDPAP) services; 12 hours per day, 7 days per week, for a total of 84 hours.

The health plan's determination of medical necessity is overturned in whole.

Yes, the requested health service/treatment of an Increase in Consumer Directed Personal Assistance Program (CDPAP) services; 12 hours per day, 7 days per week, for a total of 84 hours is medically necessary for this patient.

The patient had a telephonic assessment tool performed and this was compared to an "in person" assessment tool. The patient had documented increased care needs with tasks of walking, locomotion, and toilet use. All these tasks are performed with her unpredictable and unscheduled care needs of toileting and incontinence care. The insurer failed to document a plan to address these unpredictable and unscheduled care needs. The plan assumed the patient had informal help outside of all the hours of CDPAP services. The patient's family is not able to perform informal care. The increase in CDPAP services is not solely for safety and supervision, but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met with medical supplies and equipment alone. 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 12 hours/day, 7days/week, to total 84 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.

Therefore, the CDPAP services 12 hours/day, 7days/week, to total 84 hours/week are medically necessary for this patient.