Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Chronic pain, Dizziness, and Cardiopulmonary disease. 
Treatment: Consumer Directed Personal Care Assistance Services (CDPAS) for a total of 46 hours per week.

The insurer denied coverage for the requested CDPAS for a total of 46 hours per week.

The denial is overturned. 

This is a female patient who has an extensive medical history associated with functional impairment, who needs assistance with most daily activities. The patient is currently approved for Consumer Directed Personal Assistance Services (CDPAS) 27 hours per week. She lives alone and her daughter (who is the CDPAS aide) stays with her most of the day until late evening. The patient (via designee) requested increase of CDPAS to 46 hours per week which was denied by the insurer. 

Uniform Assessment System (UAS) documentation was provided for review. The functional status report indicates the patient needs maximal assistance for all household related tasks (meal preparation, housework, shopping) and extensive assistance for all other instrumental activities of daily living (IADLs), except phone use (limited assistance).  For activities of daily living (ADLs), the patient needs extensive assistance for bathing, lower body dressing, toilet use; and limited assistance for most other ADLs, except bed mobility and eating (independent setup help). The patient's cognition is not fully described in the available records; but the UAS includes diagnosis of vascular dementia.

The patient's medical history provides several probable causes for her physical functional impairment: chronic pain, dizziness, and cardiopulmonary disease. Considering the patient's medical history and functional impairments, caregiver assistance for ADLs and IADLs is medically necessary every day at various times throughout the day for the patient's health and safety. Without adequate assistance, the patient is at risk for adverse health events, e.g. falls/household accidents; decreased food/fluid intake (risk of malnutrition, dehydration, hypoglycemia); uncontrolled blood glucose (due to inability to self-administer insulin); incontinence associated skin damage.

The patient currently is approved for CDPAS 27 hours per week, which is 5-6 hours per day, 5 days per week. Hours need to be expanded to 7 days per week; but 5-6 hours per day is not sufficient for the broad scope of services the patient needs each day, including: all routine ADLs (morning and evening); household related tasks/shopping; all meals/snack preparation and assistance/supervision with eating; assistance with walking and transfers which can occur at any time of the day; toileting and, if necessary, incontinence care which can occur at any time of the day; medication administration (pills and injections up to 4 times per day, up until bedtime). It was also noted by the daughter that she takes her mother to therapy twice per week. 

The request for additional CDPAS hours is for 46 hours per week. The daughter is in her mother's home from 8am until 11pm, so the hours can be distributed as needed to cover the times of the day the patient needs care. This is a more realistic allocation and amount of hours per week and per day to accommodate the patient's various daily care needs; both scheduled and unscheduled. There are no other informal caregivers identified who provide assistance to the patient. Therefore, the daughter as CDPAS aide provides all necessary care. The number of hours approved should reflect the extent of the patient's daily care needs and full range of time that services are needed, i.e. morning through evening, 7 days per week. 

The health plan did not act reasonably with sound medical judgement.

The medical necessity for the requested Consumer Directed Personal Care Assistance Services (CDPAS) for a total of 46 hours per week is substantiated. The insurer's denial is overturned.