Appeal type: Medical necessity
Decision: Overturned

Diagnosis: focal partial epilepsy intractable, anxiety disorder, insomnia, and foot and back pain 

Treatment: Consumer Directed Personal Care Assistance

The insurer denied coverage for consumer directed personal assistance services. The denial reversed.

This patient is a female who lives alone. Other than the UAS and M11Q no other records were provided for review. The patient's medical history is a combined list from the UAS, M11Q and the advocate from the home health agency who submitted the appeal for the patient. The UAS indicates that the patient needs help with some daily activities, and allocated several hours a week for IADLs on the UAS-ATSP. The insurer denied request for CDPAS. The UAS identifies the patient's medical history to include partial/focal seizures (taking AED), urinary incontinence, anxiety, foot deformities (heel, toe). M11Q indicates h/o frequent seizures/syncope episodes (not clear if syncope is a separate event or associated with seizure disorder).The advocate requesting the appeal for the patient includes additional diagnoses including vestibulopathy, vertigo, depression, memory difficulties and other symptoms as a result of traumatic brain injury (the nature of the 'other symptoms' and details of TBI are not noted). The UAS identifies some cognitive problems including difficulty with making decisions in new situations, short term memory impairment and MMSE score 23/30 (which is consistent with mild cognitive impairment). These cognitive deficits may be associated with the patient's reported history of traumatic brain injury. The advocate reports that the patient is not able to advocate on her own behalf. She has difficulty completing daily activities on her own. 

There is some concern regarding the patient's mental function, and it appears that this was a key issue in the advocate's letter. On the mini mental exam (MMSE), the patient lost 2 points for memory questions, but had the most difficulty with attention and calculation, and copying the design; indicating the cognitive problems are partly but not only memory. The assistance needed for housekeeping activities may be mostly due to back and lower extremity pain, but the need for assistance with medications and finances is more likely due to cognitive deficits. Although the patient does not need hands on assistance for ADLs, it is noted that she needs setup help with many self-care ADLs including bathing, personal hygiene dressing; i.e. providing and setting up the items needed for these activities.

Without additional medical history the full extent of the patient's physical and cognitive impairments cannot be adequately assessed in the context of daily functioning. However, it appears that there is sufficient information to support the need for some assistance at home with daily activities based on lower extremity pain and cognitive deficits described in the UAS and by the advocate. The UAS-ATSP Summary of Hours Recommended allocated 11.63 hours for IADL assistance. The UAS does not indicate need for hands on assistance with ADLs. However, considering the patient has some cognitive deficits, it appears that it would be useful to the patient to have the aide provide setup help for daily self-care ADLs including bathing, dressing, personal hygiene, and if necessary, toileting needs. In the UAS, all these ADLs were identified as needing set up help, which includes preparing items needed for ADL tasks, with cues provided when needed.

The patient has no informal caregivers. It appears that she has functional needs for daily activities based on physical and cognitive deficits. It is in the best interest of the patient to initiate daily support through personal care services (in this case CDPAS). 

It is recommended that consumer directed personal assistance services are approved for 14 hours per week.

Based on the above, the medical necessity for Consumer Directed Personal Care Assistance is substantiated.  The insurer's denial is reversed.