Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus type 2; pain, bunion right foot/hallux valgus; difficulty walking; osteoarthritis

Treatment: Consumer Directed Personal Care Assistance Services increase to 6 hours per day, 7 days per week (Monday through Sunday) for a total of 42 hours per week

The insurer denied coverage for Consumer Directed Personal Care Assistance Services increase to 6 hours per day, 7 days per week (Monday through Sunday) for a total of 42 hours per week. The denial is reversed.

This patient is a female with diagnoses that included hypertension, hyperlipidemia, diabetes mellitus type 2, pain, bunion right foot/hallux valgus, difficulty walking, osteoarthritis, asthma, urinary incontinence, and insomnia. She has been receiving consumer directed personal assistance services (CDPAS) to assist with IADLs and ADLs. The patient lives with her granddaughter who works and goes to school and does not provide assistance to the patient with daily activities. At the time the UAS was done, the patient was planning to have surgery on her right bunion. She requested an increase of CDPAS hours from 28 to 42 per week to increase assistance with daily activities following surgery on right foot. The request was denied. Surgery was performed. Patient wrote in the appeal application that she is unable to stand or walk without assistance. An external appeal was requested.

Prior to foot surgery, the patient's functional status was impaired due to various contributing factors. The patient reported stabbing pain to both feet. The patient has diabetes mellitus. The bilateral foot pain she describes may be due to neuropathy. She also has osteoarthritis. It was noted she has limited range of motion affecting her ability for lower body dressing, suggesting restricted movement of back, hips or knees. It is not clear how much the bunion affected her mobility. It was noted in the UAS that patient walks with an unsteady gait and assistive device, and has limited ability to stand and walk for long periods of time (prior to surgery). 

The patient has dyspnea with exertion which is attributed to asthma. The frequency of acute episodes is not noted. Patient reported she always had shortness of breath with normal daily activities. There may be additional causes for her dyspnea. The patient smokes cigarettes and there may be some component of COPD affecting her breathing on a chronic basis. The patient's BMI indicates obesity. Dsypnea on exertion is associated with obesity and may be another factor for her chronic dyspnea.

The patient was receiving CDPAS 3-6 hours per day prior to surgery. She is requesting 6 hours per day, 7 days per week. Considering the patient's mobility is restricted for a substantial amount of time during the healing and recovery process, it is realistic to expect that she needs more assistance for all weight-bearing activities until she can return to full weight-bearing status. This includes transfers, walking, toileting, bathing and most household tasks. Increase of personal care services (in this case CDPAS) is medically necessary in order to facilitate safe completion of ADLs and IADLs, decrease physical burden of performing daily tasks, and help facilitate healing by improving compliance with weight-bearing restrictions.   

Consumer Directed Personal Care Assistance Services 6 hours per day, 7 days per week, total of 42 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the requested Consumer Directed Personal Care Assistance Services increase to 6 hours per day, 7 days per week (Monday through Sunday) for a total of 42 hours per week is substantiated.  The insurer's denial is reversed.