Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular disease
Treatment: CDPAP (Consumer Directed Personal Assistance Program) services
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 6 Hours per Day, 5 Days per Week and 5 Hours per Day, 2 Days per Week (Total Amount of 40 Hours per Week). The health plan's determination is overturned. 

The patient is a female with past medical history of cerebrovascular disease, multiple brain meningioma, hearing loss, urinary incontinence, hypertension, lymphoma, low back pain, hyperlipidemia, and coronary artery disease who had been assigned CDPAP (Consumer Directed Personal Assistance Program) services based on assessment tool performed via telephone which assessed the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while limited assistance with tasks of managing finances, stairs, transportation, bathing, dressing upper/lower body, and transfer toilet. With tasks of managing medication, walking, and locomotion the patient was assessed at supervision, while set up only with task of phone use and independent with tasks of personal hygiene, bed mobility, and eating. The patient's PCP (primary care provider) provided a letter stating the patient had been suffering from progressive brain tumor/meningioma with worsening dizziness and hearing loss in the last 3 months. The letter also noted the patient had started radiation therapy to control clinical symptoms and was under the care of oncology for chronic lymphoma. Lastly, the letter stated based on the patient's medical condition significantly deteriorating in the last 3 months, she needed extended home care hours to help her with activities of daily living.

Consumer Directed Personal Assistance Program (CDPAP) Services: 6 Hours per Day, 5 Days per Week and 5 Hours per Day, 2 Days per Week (Total Amount of 40 Hours per Week) are medically necessary for this patient.
There is documentation by the patient's PCP of worsening functional status due to progressive brain meningioma and subsequent radiation therapy. The universal assessment performed showed an increase in assistance needs with tasks of stairs, transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet. The patient requires multiple doctor appointments for follow-up of her multiple medical problems including recent radiation treatment. The patient's PCP documented medical necessity for increase in CDPAP services. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)/ Instrumental activities of daily living (IADL). The patient's assistance needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 6 hours/day, 5 days/week, and 5 hours/day, 2 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.