Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Spinal Stenosis

Treatment: Consumer Direct Personal Assistance Services 12 hours per day, 7 days per week (total of 84 hours per week)

The insurer denied the Consumer Direct Personal Assistance Services 12 hours per day, 7 days per week (total of 84 hours per week) 

The denial was overturned.

This is a female patient who has a medical history of has osteoarthritis, spinal stenosis, degenerative disc disease, osteoporosis, status post hip fracture. The patient is totally dependent or needs maximal assistance for all IADLs; except phone use (extensive assistance).  For ADLs, the patient is totally dependent or needs maximal assistance; except for personal hygiene and eating (extensive assistance).  The patient is wheelchair bound (wheeled by caregiver).  The UAS reports patient's cognition as modified independence for decision making for daily tasks; forgetful at times, but no significant short term or procedural memory deficits noted.  The patient does not have significant cognitive impairment; and so the primary cause of the patient's functional impairment is most likely due to medical conditions causing physical limitations to mobility, which was exacerbated by the recent fall.

For elderly people, functional impairment is often the result of cumulative effects from various chronic conditions.  Acute injury or illness often causes further functional decline.  Depending on various factors the patient may or may not return to the level of function prior to the acute event.  Falls are a common cause of functional decline; sometimes due to a serious injury (e.g. hip fracture, head trauma); and at times due to less severe injuries which can also cause significant pain and decreased mobility.  In this case, the patient was already significantly compromised in her ability to perform daily activities before the patient's fall.  As a result of the fall and new injury, she became wheelchair bound, and totally dependent in some additional ADLs.

Due to the patient's incontinence and immobility, she is at risk for pressure ulcers.  The patient needs maximal (weight-bearing) assistance for bed mobility. It appears very unlikely the patient is able to reposition herself properly and with sufficient frequency to provide adequate pressure relief for all the hours she is in bed.  Practice standards for turning and repositioning for pressure relief is generally every 2 hours, but can vary with individual circumstances.  The turn and position schedule for the patient needs to be determined by the patient's physician and nursing assessment; but considering the patient's risk factors for pressure ulcers (incontinence, immobility), it is expected that over the course of the evening and night, several position changes are indicated.  Pressure ulcers are a source of pain and associated with substantial morbidity, including infection/sepsis and possible surgical intervention.  Pressure ulcer prevention is high priority for the patient's care plan.

Recommendation is given for approval of Consumer Directed Personal Assistance Program services 12 hours per day, 7 days per week, total of 84 hours per week. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for CDPAS 12 hours per day, 7 days per week (total of 84 hours per week), is overturned.  The medical necessity is substantiated.