Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis (ALS)
Treatment: Consumer directed personal assistance services, 8 hours per day, 5 days per week (Monday-Friday), a total of 40 hours per week. 
The insurer denied consumer directed personal assistance services, 8 hours per day, 5 days per week (Monday-Friday), a total of 40 hours per week. 
The determination is overturned.

The patient has a past medical history of amyotrophic lateral sclerosis (ALS), hyperlipidemia, hypothyroidism, anxiety, and depression who had been assigned CDPAP services 21 hours/week. There was a request to increase consumer directed personal care program (CDPAP) services and the patient underwent a telephonic assessment tool assessing the patient at maximum assistant with meal preparation, ordinary housework, and equipment management while extensive assistance with tasks of shopping and dressing upper/lower body. With the tasks of managing finances, managing medication, phone use, stairs, transportation, bathing, personal hygiene, and toilet use, the patient was assessed at limited assistance while independent with the tasks of walking, locomotion, bed mobility, and eating.

Notes from the assessment stated the patient needed assistance with Instrumental activities of daily living (IADLs) and activities of daily living (ADLs) due to amyotrophic lateral sclerosis (ALS) which caused tiredness, weakness, and dysarthria. The patient had a follow-up with her neurologist noting the patient had coronovirus disease (COVID) in December and January, had dysarthric speech, took longer to eat her meals, had difficulty with drooling, and had weakness of her right hand.

The insurer provided a final adverse determination denial notice denying the request to increase CDPAP services stating the patient's daughter had reported that the patient had progressive ALS and had been experiencing multiple falls. The denial also stated the daughter had reported she had been working from home but had to return to work in the office and was getting married and would be leaving the patient's home. In addition, the denial stated the patient's personal care task could still be done in the time that had been provided during the current hours she received with her plan of care. The denial also stated the patient should follow up with her doctor regarding the symptoms she was reporting. Lastly, the denial stated the patient should discuss with her CDPAP caregiver a schedule that would better fit her needs.

The patient again saw her neurologist noting that both of her arms had become weaker and gave out, was unable to fasten buttons and pull zippers, fell one time from a chair that did not have an armrest and was unable to get up by herself off the floor, needed assistance in the bathroom getting clothes and pants off, had to have her food cut up for her, and noted the daughter worked during the day and was unable to assist the patient with her needs while the daughter was at work. The patient was working with physical therapy and occupational therapy. The patient's neurologist provided a letter stating the patient's diagnosis of ALS and noting it was a chronic, terminal, degenerative neuromuscular disease and progressive neuromuscular condition that resulted in progressive paralysis and respiratory failure. The neurologist's letter also stated that at the patient's recent visit the patient had symptoms of increased weakness and poor range of motion, tiring easily with routine tasks and needing assistance with all toileting, dressing, grooming, bathing, meal preparation, feeding, medication preparation, errands, personal task, and any activity of daily living that require use of her arms or hands. The letter from neurology also stated the patient was unable to use assistive devices when walking due to her lack of upper body strength. Lastly, the provider's letter stated the patient required an increase in the number of home health aide hours in order to meet her needs. The patient's medical provider appealed the denial decision to increase CDPAP services.

At issue is the medical necessity of consumer directed personal assistance services, 8 hours per day, 5 days per week (Monday-Friday), a total of 40 hours per week. 

Tthe services are medically necessary. The patient's medical provider documented the patient's medical diagnosis of ALS which is a chronic and progressive neuromuscular disorder. There was documentation from the neurologist that the patient had progressive weakness and worsened dysarthria. The patient required assistance with all ADLs although the last telephonic assessment tool indicated she was independent with walking, locomotion, transfer toilet, bed mobility, and eating, therefore the telephonic assessment tool performed underestimated her care needs. The patient's neurologist noted the patient was unable to ambulate without assistance, was unable to eat without assistance, and required assistance with toilet use, transfer toilet and bed mobility. The patient's daughter who was an informal helper was no longer available to provide informal help given her work hours and need to return to in person employment. The patient's ADL and IADL care needs cannot be met with the current CDPAP hours and/or with adaptive equipment and/or with 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/IADLs. 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 8 hours/day, 5 days/week, to total 40 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.