Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar Disorder and Unspecified Anxiety Disorder

Treatment: Consumer Directed Personal Assistance Services (CDPAS)

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS). The denial was upheld.

This patient is a female who was requesting consumer directed personal assistance services. She had diagnoses of Bipolar Disorder and Unspecified Anxiety Disorder. She also had diabetes. It was reported that she took Risperidone and Sertraline and was attending biweekly psychotherapy. She was unemployed and lived with her siblings. The request was for consumer directed personal assistance services (CDPAS).

The insurer denied coverage for consumer directed personal assistance services (CDPAS). This reviewer agrees with the decision to deny coverage for consumer directed personal assistance services (CDPAS) as the chart notes provided did not provide enough specific evidence to support that she required this level of care.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. The Department of Health reports that personal care services (PCS) helps people with everyday tasks including activities of daily living or household tasks. It also states that personal care service attends to the physical needs of people disabled or otherwise unable to take care of themselves. Such ADLs include bathing, showering, management of bodily fluids, toileting, feeding, ambulating, transferring from bed to chair or wheelchair or in and out of the tub or shower, grooming, taking care of teeth or mouth, housekeeping, or meal preparation. It involves a physician to order the services and then a nursing and/or social work assessment to be done.

In this case, this patient did not have reported difficulties ambulating, bathing, showering, brushing her teeth, and reportedly had some independence with ADLs.  It was reported that she was independent with toileting and eating and required only set up with personal hygiene, was alert and oriented times 3, and had no mood or behavioral symptoms, hallucinations, delusions, or abnormal thoughts. It was reported that she required only limited assistance with bathing and was independent with locomotion and toileting use. She required assistance with meal preparation and shopping, but was able to take her medications and utilize the telephone. It was reported that she had appropriate judgment, was self-directing, could describe her emergency plan including calling 911, was able to express her ideas without difficulty, and had clear comprehension. It was reported that her psychiatric symptoms were well controlled and that she was compliant with visits and medications. 

The chart documentation did not provide enough specific evidence to support that consumer directed personal assistance services (CDPAS) was the least restrictive medically necessary service for this patient. As a result, uphold the previous decision and deny coverage for consumer directed personal assistance services (CDPAS).  The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

Based on the above, the medical necessity for Consumer Directed Personal Assistance Services (CDPAS) is not substantiated.  The insurer's denial is upheld.