Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied CDPAS services. 
The denial is overturned in whole.

The patient is a  female with past medical history of diabetes mellitus (DM) Type 2 and multiple orthopedic surgeries resulting in chronic pain and limitation of the neck, back and bilateral lower extremities who had been assigned 15 hours/week of Consumer Directed Personal Assistance Services (CDPAS) through her former health plan. The patient had a change in insurance and requested continuation of CDPAS with her provider completing Department of Health (DOH) form 4359 stating the patient's medical conditions, noting the patient cannot perform repetitive bending, twisting, sitting/standing longer than 60 minutes, and not being able to lift over 5 pounds, and also noting the patient's symptoms of dizziness, weakness, numbness, unsteadiness, frequent falls, and multiple joint pain.

The subject under review is the medical necessity for consumer directed personal assistance services.

The health plan's determination is overturned in whole.

Consumer directed personal assistance is medically necessary for this patient. "Consumer directed personal assistant" means an adult who provides consumer directed personal assistance to a consumer under the consumer's instruction, supervision and direction or under the instruction, supervision and direction of the consumer's designated representative. A consumer's spouse, parent or designated representative may not be the consumer directed personal assistant for that consumer; however, a consumer directed personal assistant may include any other adult relative of the consumer who does not reside with the consumer or any other adult relative who resides with the consumer because the amount of care the consumer requires makes such relative's presence necessary.
The patient's CDPAS cannot be her significant other based on this definition. The patient does not require 24 hour care or at least 16 hours/day of care and therefore does not fit the definition of live-in CDPAS services as above.
The patient does need assistance with ADLs (activities of daily living) and Instrumental activities of daily living (IADLs) which are underestimated in her telephonic assessment tool and as noted by letters provided by her physical therapist, primary care physician, and neurosurgeon. The patient should be approved for CDPAS performed by another designee of the patient.
The patient has chronic physical mobility issues related to chronic bilateral foot pain, chronic neck and chronic back pain.  The patient has had multiple surgeries of the spine, most recently of the c-spine with C7-T1 anterior microdiscectomy and fusion.  The patient has DDD and degenerative joint disease (DJD) of the cervical and lumbar spine with chronic pain.  The patient had surgeries on her feet (left calcaneal osteotomy), (right calcaneal osteotomy), (removal of hardware right foot), (right subtalar joint fusion), (right tenosynovectomy  and left peroneal synovectomy), (left calcaneal hardware removal), (left foot triple arthrodesis and left posterior tibial tendon debridement).  Due to her medical conditions above she needs assistance with meal preparation, ordinary housework, stairs, shopping, and bathing.  

Consumer directed personal assistance 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.