Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional Limitations; impaired vision; decreased range of motion

Treatment: Consumer Directed Personal Care Assistance Program (CDPCAP) services, 11.5 hours per day, 7 days per week (80.5 hours per week)

The insurer has denied coverage for coverage for Consumer Directed Personal Care Assistance Program (CDPCAP) services, 11.5 hours per day, 7 days per week (80.5 hours per week).  The denial was reversed.

This is female patient lives at home with her relative who serves as the CDPAP aide. The records indicate that the patient's functional limitations are associated with impaired vision (legally blind), decreased range of motion, pain, decreased strength of upper and lower extremities, and most recently hip fracture which appears to have been treated non-surgically. (Note: The UAS documents right hip fracture but medical records from physician house call visit identify fracture as left hip; x-ray report is for left hip). The underlying cause of weakness and decreased range of motion (other than the left hip) is not clearly identified. In one "comment" section of the mid-2019 UAS, it is noted that the patient has OA. Osteoarthritis can cause various types of physical impairments and is associated with symptoms including pain, stiffness, and decreased range of motion which result in functional decline for ADLs and IADLs. The hip fracture was not surgically treated and most likely increased the patient's level of disability for out of bed mobility including walking, transfers and toileting. 

The plan previously approved CDPAP 6.5 hours per day, 7 days per week; 45.5 total hours per week. The patient requested an increase in services: CDPAP 11.5 hours per day, 7 days per week; total of 80.5 hours per week. In response to this request, the plan denied request for CDPAP 80.5 hours per week; and approved CDPAP 9 hours per day, 7 days per week, a total of 63 hours per week. An appeal was requested. In response, the plan denied further increase of CDPAP services; plan approval stays at CDPAP 9 hours per day, 7 days per week; 63 total hours per week.

In elderly people, the presence of multiple co-morbidities is common; and the consequences on functional ability are a combined and interactive effect of all the existing medical conditions. For this patient with vision loss, fracture, arthritis, and incontinence, each alone would present significant functional challenges. Together they result in even greater risk of adverse health events, for example: greater risk of falls (which caused her fracture); difficulty navigating her home due to physical and vision impairments; greater difficulty managing incontinence which increases risk of skin injury and falls.

The insurer approved an increase of personal care services (through CDPAP) for 9 hours per day, 7 days per week; however, this is still insufficient for a person who is blind, incontinent, and totally dependent on caregiver assistance for all ADLs. Due to the extent of the patient's functional disability and the adverse consequences of not having assistance when needed (as noted above), it is medically necessary that she has caregiver assistance throughout the day. A relative who lives with the patient is the CDPAP aide.

Consumer Directed Personal Assistance Program services are approved for 11.5 hours per day, 7 days per week, total of 80.5 hours per week. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest. Based on the above, the medical necessity for Consumer Directed Personal Care Assistance Program (CDPCAP) services, 11.5 hours per day, 7 days per week (80.5 hours per week) is substantiated.  The insurer's denial is reversed.