Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, Diabetes
Treatment: consumer directed personal assistance program (CDPAP): 5 hours per day- 7 days per week- for a total of 35 hours per week

The insurer denied coverage for consumer directed personal assistance program (CDPAP): 5 hours per day- 7 days per week- for a total of 35 hours per week

The denial is overturned

This is a patient with chronic medical problems including hypertension, diabetes and coronary artery disease. The patient underwent a cholecystectomy with reported recurrent abdominal discomfort. The patient lives in a 2-bedroom private residence. The patient's daughter is involved and supportive in their care. The patient also receives social day care services 2 days a week. The patient is approved for consumer directed personal assistance program (CDPAP) 21 hours/week. The request is for CDPAP: 5 hours per day- 7 days per week- for a total of 35 hours per week, leading to an external review. 

The Uniform Assessment System (UAS) report is reviewed. The patient's cognition is described as minimally impaired. The patient reportedly requires maximal assistance to total dependence for performing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for lower body dressing. Extensive assistance is reportedly required for bathing, personal hygiene, toilet transfer/use, locomotion and ambulation (uses a cane). Limited assistance is reportedly needed for upper body dressing. The patient is independent with eating and bed mobility. 

The patient reports being frequently incontinent of bladder and occasionally incontinent of bowel. The patient's ability to perform activities of daily living (ADLs) and self-sufficiency have reportedly deteriorated and declined, respectively over the prior 90 days. There have been no reported falls over the prior 90 days. The patient's cognitive and functional ability have declined when compared to the previous UAS report. 

The patient's clinical condition and functional deficits are at a level or unpredictable as to require an increase in CDPAP 5 hours per day- 7 days per week- for a total of 35 hours per week. The letter from the patient's treating physician discussing the patient's clinical condition and requesting "to increase the patient's CDPAP hours for homecare" was reviewed. The patient's physician did not provide the associated treatment notes to support their claim of the patient's reported decreased functional capacity. However, the patient's cognitive and functional deficits have significantly declined and support the requested increase CDPAP 5 hours per day- 7 days per week- for a total of 35 hours per week. 

From a physical medicine and rehabilitation perspective, the requested increase CDPAP: 5 hours per day- 7 days per week- for a total of 35 hours per week is medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for consumer directed personal assistance program (CDPAP): 5 hours per day- 7 days per week- for a total of 35 hours per week is substantiated.