Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: consumer directed personal care services increase from 35 hours a week to 84 hours a week
The insurer denied the consumer directed personal care services increase from 35 hours a week to 84 hours a week
The determination is overturned.

The patient has a past medical history of hearing loss, diabetes mellitus type 2, urinary incontinence, gastroesophageal reflux disease (GERD), hypertension, hyperlipidemia, and osteoarthritis who had consumer directed personal assistance program (CDPAP) services 5 hours/day, 7 days/week, to total 35 hours/week. The patient was hospitalized with a cough and shortness of breath. There was a request to increase personal care assistance (PCA) services and the patient underwent a telephonic assessment assessing the patient at total assistance with the tasks of ordinary housework and maximum assistance with the tasks of meal preparation, stairs, shopping, and transportation. With the tasks of managing finances, managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with bed mobility and independent with eating.

Notes from the assessment stated the patient lived with her son's family and the caregiver had her own medical issues and could no longer assist the patient on her own. In addition, notes from the assessment stated that the patient needed assistance with incontinence cares, toilet use, and transfers.

The insurer provided an initial adverse determination denial notice denying the request to increase CDPAP services to 84 hours/week but partially approving 42 hours/week. The denial stated that the plan recommended splitting current hours into 2 shifts to meet morning and evening needs and the plan did not provide an aide when a task was not being done. The plan recommended that the patient use her walker to maintain safety and use incontinent adult pull-ups to manage toileting needs. A commode, raised toilet seat, and toilet grab bars were also recommended. The daughter requested a fair hearing regarding the denial decision stating the patient is unable to do anything on her own needing assistance with walking, errands, laundry, food, cleaning, and bathroom monitoring.

The insurer sent a final adverse determination denial notice denying the request to increase CDPAP services to 84 hours/week and continued to approve 42 hours/week. The denial noted the daughter requested to increase CDPAP services as the patient needed help with cooking, cleaning, and laundry. The daughter also stated that the patient could not do anything on her own. The denial stated the assessment noted the patient needed help with cooking, cleaning, housekeeping, bathing, dressing, and toileting. The denial also stated that the daughter noted the patient's medical condition was getting worse after hospitalization and the plan stated that aides do not manage medical conditions as it is beyond their scope of practice. The plan also recommended physical therapy (PT) and occupational therapy (OT) to gain strength, endurance, and the ability to move about better. Lastly, the denial stated that time was not provided for safety supervision, companionship, or when there are no tasks being done.


Yes, the services are medically necessary.

The patient has chronic progressive medical conditions of osteoarthritis with worsening physical and mental functioning following hospitalization. There is documentation that the patient's current caregiver has her own medical issues and can no longer assist the patient. The plan did not address the patient no longer having the same amount of informal help. The patient requires at least limited assistance with all activities of daily living (ADLs) except eating and the patient would require CDPAP services outside of the time that she does have informal help. The patient has urinary incontinence and requires assistance with toilet transfer, toilet use, and incontinence care. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient's care needs cannot be met with the current hours and/or adaptive equipment and/or medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 84 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.