Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fibromyalgia, rheumatoid arthritis
 
Treatment: Consumer Directed Personal Assistance Program 

The insurer denied coverage for Consumer Directed Personal Assistance Program. The denial is reversed. 

This patient is a female with multiple medical conditions, including chronic pain due to various causes (arthritis, fibromyalgia, neuropathy).  She has been receiving consumer directed personal assistance services (CDPAS); most recent approval was for 39.5 hours per week.  As per the explanation in the insurer's final adverse determination notice, the patient was due for a nursing re-assessment in order to recertify CDPAS.  NYS regulations for re-authorization of CDPAS require a physician's order prior to assessment by a nurse.  The order must address specific information including: diagnoses, treatment, patient's condition and need for skilled and/or personal care services.  The order and necessary information is included in the form: DOH-4359 Physician's Order For Personal Care/Consumer Directed Personal Assistance Services.  The insurer indicated that several requests for the order were sent to the physician. 

The physician's appeal letter explained the following: The patient was examined, and the order form was faxed to the insurer.  When the physician was informed that the order was not dated, his office requested a copy of the signature/date page from the insurer (this page could not be located in the physician's office).  The physician reported that the signature page was not received from the insurer.  Finally, another order was completed, signed and dated and faxed to the insurer, but the following week the physician was informed that services were denied, and an appeal would be necessary.  

Stopping personal care services without an assessment of the patient's current medical and functional status places the patient at risk for adverse health and safety events.  Considering the patient's medical history (including arthritis, fibromyalgia, neuropathy) and information in the physician's order, (i.e. mobility problems due to chronic pain), it is not in the patient's best interest to discontinue personal care services without an assessment to determine her needs.  

The physician's appeal letter and various case review notes from the insurer provide documentation of an extensive series of phone calls, voice mail messages and fax transmissions.  It is acknowledged that both parties were acting with good intentions.  It is also understood that delays in communication between medical providers and insurers occur.  However, these types of problems should not be the reason a patient stops receiving personal care services.  Even though the date of the physician's signature on the original order was missing, there is documentation to confirm that the order was completed, signed and faxed to the insurer within 30 calendar days of the medical exam.  Based on the physician's appeal letter and order form for personal care services, it is apparent that the physician considers personal care services medically necessary for the patient.  There appears to be sufficient information to support medical necessity for the patient to have nursing re-assessment for CDPAS.

Approve CPT Code T1001 - Nursing (RN) assessment for recertification of Consumer Directed Personal Assistance Services.  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 Code T1001, Nursing Assessment, for recertification of Consumer Directed Personal Assistance Services (CDPAS) is substantiated.  The insurer's denial is reversed.