Appeal type: Medical necessity
Decision: Overturned

Diagnosis: macular degeneration.
Treatment: personal care hours to 66.5 per week. 
The insurer denied increase in personal care hours to 66.5 per week. 
The denial is overturned.

The patient is a female with past medical history of macular degeneration, coronary artery disease, cerebrovascular accident (CVA), pulmonary fibrosis, pulmonary hypertension, irritable bowel syndrome (IBS), urinary incontinence, bowel incontinence, breast cancer, hyperlipidemia, gastroesophageal reflux disease (GERD), and hypothyroidism who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 4.5 hours/day, 7 days/week, to total 31.5 hours/week based on assessment performed telephonically on assessing the patient at total assistance with tasks of ordinary housework and managing finances while maximum assistance with tasks of meal preparation, managing medication, shopping, and transportation. With tasks of bathing and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of phone use, stairs, dressing upper body, walking, locomotion, transfer toilet, and toilet use. The patient was assessed at supervision with tasks of eating while independent with task of bed mobility. There was a request to increased CDPAP services and the patient underwent another assessment assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, shopping, and transportation. With tasks of bathing, dressing lower body, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of phone use, stairs, dressing upper body, walking, locomotion, and transfer toilet. The subject under review is the medical necessity for 66.5 hours a week of consumer directed personal assistance services.

The requested 66.5 hours per week is medically necessary for this patient. There is documentation from the patient's medical provider of increased assistance needs with Instrumental activities of daily living (IADLs)/ADLs due to the patient's progressive macular degeneration and shortness of breath due to pulmonary fibrosis. The patient has an increase in assistance need with toilet use when comparing assessment to assessment. The patient has bowel incontinence and requires extensive assistance with toilet use and incontinence cares. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet the patient's unscheduled and unpredictable care needs. The insurer incorrectly assumed the patient had informal help outside of the currently assigned CDPAP service hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 66.5 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.