Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Pain. 
Treatment: Home Care/Personal Care Consumer Directed Personal Assistance Services (CDPAS) increase to 70 hours per week. 
The insurer denied coverage for Home Care/Personal Care Consumer Directed Personal Assistance Services (CDPAS) increase to 70 hours per week. 
The denial is upheld. 

This case pertains to a patient who lives with a relative. The patient has diagnoses of chronic pain, cardiac arrhythmia, vitamin D deficiency, right fascicular block, gait abnormality, fatigue, spinal stenosis, asthma, heart failure, pain, edema, hypertension, hyperlipidemia, diabetes type 2, arthritis, shortness of breath, dizziness and giddiness, gout, atherosclerotic heart disease, sleep apnea, stress incontinence, varicose veins, deformity of lower leg, chronic ischemic heart disease and urinary incontinence. The patient's medications include albuterol, allopurinol, aspirin, Deltasone, Diovan, eplerenone, Kapspargo, Lasix, metformin, Neurontin, Repatha, Trulicity, Ventolin, and vitamin D. 

The provider noted the patient is under their care for a neurological condition. The patient has difficulty ambulating and has severe pain with sitting, standing, and walking. The patient is in need of assistance for daily living. The patient would need at least 10 hours per day, 7 days per week to assist with fall precautions, medication intake, groceries, laundry. 

The provider notes that since the last time patient was seen, 2 months ago, their condition has worsened. The patient has become more unstable with a tendency to fall, and is also experiencing more dizziness. The patient now has more difficulty swallowing food. The pain in the patient's knee and back has worsened as well. 

The provider noted the patient was being followed for diabetic non-proliferative retinopathy in both eyes. Due to the instability of the blood sugar, the patient's vision is constantly fluctuating and is the cause of a lot of blurring in both eyes. 

The provider noted the patient has severe diastolic congestive heart failure. The patient is very limited in their ability to ambulate and to perform activities of daily living (ADLs). 

The patient's cognitive skills are moderately impaired, cues/supervision are always required. The patient is alert and oriented x 3 and can make their basic needs known. The patient has forgetfulness with their short-term memory. The patient ambulates with a cane with an unsteady gait. The patient is occasionally incontinent for bladder and continent for bowel. The patient is not at risk for pressure ulcers. The patient is totally dependent for meal preparation and housework. The patient requires maximal assistance with shopping. The patient requires extensive assistance with bathing, dressing lower body, ambulation, toileting, and toilet transfers. The patient requires limited assistance with dressing upper body, personal hygiene, bed mobility and eating. 

The tasking tool noted the need for 33.42 hours weekly. This was figured on 5 days per week. With 7 days per week, it brought the need to 43.5 hours per week. The plan awarded 56 hours per week. This allots 8 hours per day of personal assistance. The assessment and the tool did not find any need for additional time. The decision to deny an increase to 70 hours per week is upheld. 

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. 

The increase of home care/personal care consumer directed personal assistance services to 70 hours per week is not considered medically necessary for this patient. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Home Care/Personal Care Consumer Directed Personal Assistance Services (CDPAS) increase to 70 hours per week is not substantiated.