Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Palsy
Treatment: increase in consumer and self-directed personal assistance services (CDPAS) to 35 hours per week
The insurer denied an increase in consumer and self-directed personal assistance services (CDPAS) to 35 hours per week for medical necessity. 
The denial was overturned in whole. 

The patient is a female with a past medical history of cerebral palsy, spastic diplegia, asthma, hand osteoarthritis, flexor pollicis longus tunnel syndrome, eczema, urinary incontinence, and bowel incontinence who had been assigned consumer and self-directed personal assistance services (CDPAP) services 3 hours/day, 2 days/week, and 2 hours/day, 5 days/week, to total 16 hours/week based on assessment tools. 
The patient's ex-husband stopped providing CDPAP services and there was a request to increase CDPAP services to 35 hours/week.  The patient had a fallwhile getting out of the tub, and 911 was called but the patient did not go to the hospital. The patient fell again walking in her home. The patient fell again and went to the emergency room. The patient had a telephonic assessment tool performed assessing the patient at total assistance with task of ordinary housework while maximum assistance with task of transportation. The patient was assessed at extensive assistance with tasks of meal preparation, managing medication, stairs, shopping, bathing, dressing lower body, walking, and locomotion while limited assistance with tasks of personal hygiene, dressing upper body, transfer to toilet, and toilet use. With the tasks of bed mobility and eating the patient was assessed at supervision while independent with tasks of managing finances and phone use. 
The patient's legal advocate provided a formal request for internal appeal of initial adverse determination. The denial stated the request was not medically necessary and the patient did not meet criteria. In addition, the denial stated the patient had incontinence supplies to keep her dry and a commode to assist with toileting needs, had a cane and motorized wheelchair to move about her environment, and had a Hoyer lift to help with transfers. The plan recommended physical therapy and occupational therapy and recommended the patient speak to her physician about her medical conditions and possible treatment options, and current service hours should be arranged throughout the day to best meet her needs. 
At issue is the medical necessity of consumer and self-directed personal assistance services (CDPAS), 35 hours per week.

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

Yes, the requested health service/treatment of consumer and self-directed personal assistance services, 35 hours per week is medically necessary for this patient.
The patient has documented diagnoses of cerebral palsy, spastic diplegia, chronic hand pain, urinary incontinence, and bowel incontinence. There is documented increase in assistance needs with tasks of managing medication, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, and eating. The patient has needs for a motorized wheelchair while previously using a cane to ambulate. The patient did complete physical therapy as recommended by the plan. The patient's increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/Instrumental activities of daily living (IADL)s. The patient's PCP documented medical necessity for increased CDPAP service hours. 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 5 hours/day, 7days/week, to total 35 hours/week are medically necessary for this patient.