Appeal type: Medical necessity
Decision: Overturned

Diagnosis: coronary artery disease (CAD), congestive heart failure, hypertension, atrial fibrillation, and osteoporosis

Treatment: consumer directed personal assistance program (CDPAP) services - Live-in

The insurer denied coverage for consumer directed personal assistance program (CDPAP) services - Live-in

The denial is overturned
 

Patient is an adult with a history of coronary artery disease (CAD), congestive heart failure, hypertension, atrial fibrillation, and osteoporosis. She was recently discharged from the hospital. She is becoming increasingly weak, confused and totally dependent with bathing, toileting, transfer, ambulation. She is also experiencing loss of appetite. Request is to increase consumer directed personal assistance program (CDPAP) services, 24 hours/day, live in.

An increase in consumer directed personal assistance program (CDPAP) services to Live-in, per diem: 1 day - 7 days per week is considered medically necessary for this patient.

The patient has multiple medical conditions and is not able to do her activities of daily living. The patient is weak and experiencing poor appetite and loss of mobility. The patient needs one on one assistance, 24 hours daily, as she is at high risk of complications and is in need of help and close supervision.

"This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems." (Hirdes, J. P. et al. 2022).

Per Landers, S., et al., (2016), "Medicare skilled home health" care or "home health care" refers to services offered by Medicare-certified home health agencies under the Medicare home health benefit. By contrast, "home-based care" refers to a wide array of different types of care provided in the home by a wide range of parties. The continuum of different types of home-based care delivered in the home varies in terms of different dimensions, including acuity, type of care provided, and degree of physician involvement. Home-based care includes both formal and informal personal care services, Medicare skilled home health, physician house calls, and even "hospital-at-home" services." 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in consumer directed personal assistance program (CDPAP) services to Live-in, per diem: 1 day - 7 days per week is substantiated.