Appeal type: Medical necessity
Decision: Overturned

Diagnosis: metastatic advanced lung cancer, stage IV, pleural effusion, congestive heart failure

Treatment: Consumer Directed Personal Assistance Program (CDPAP); 12 hours per day- 7 days per week; 12 hours per day 7 days per week- for a total of 168 hours per week (split-shift)

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP); 12 hours per day- 7 days per week; 12 hours per day 7 days per week- for a total of 168 hours per week (split-shift)

The denial is overturned

 
The patient is an elderly man seeking coverage for Consumer Directed Personal Assistance Program (CDPAP); 12 hours per day - 7 days per week; 12 hours per day - 7 days per week for a total of 168 hours per week (split shift).

The provider requested reconsideration for an increase in the patient's personal assistance service hours.  The patient had hip surgery.  After the surgery, the patient was not able to urinate on their own.  The patient had to be catheterized.  The patient had several failed voiding trials.  The patient had 2 urinary infections since then and was admitted to the hospital twice.  The patient had surgery for suprapubic catheter which required extensive care.  The patient had been diagnosed with colitis and had diarrhea during the day and night.  The patient was not sleeping at night and required assistance due to bowel incontinence.  In addition, the patient could not sleep at night, was having nightmares, would scream for help, and was at high risk for falls and injuries.

The patient had metastatic advanced lung cancer, stage IV, pleural effusion, congestive heart failure, history of aortic valve replacement, major depression, anxiety disorder, progressive senile dementia, chronic insomnia, chronic vertigo, abnormal gait, lumbar radiculopathy, sciatica, difficulty with walking, hypertension, hyperlipidemia, neuropathy, urinary incontinence, degenerative joint disease, bilateral knee arthritis, lumbar radiculopathy, history of hip fracture, peptic ulcer disease, and history of COVID-19 infection.  The patient had extremely limited mobility.  The patient was homebound and could not dress/undress themselves without assistance.  The patient was currently wheelchair-bound.  The patient was not able to ambulate with a walker around the home without assistance.  The patient was having episodes of confusion and disorientation to time, place, and person.  The home was the most appropriate place for the patient and the patient was motivated to stay in their home.  The patient required total assistance for personal care services with personal hygiene, dressing, feeding, and nutritional and environmental support in order to maintain their health and safety in their home.  The patient needed assistance with toileting every 1.5 hours due to C. difficile colitis.  This required the patient to be placed on a commode during the day and night.  The patient required assistance with household tasks, food shopping, and reminders for administration of medication.  The patient had additional safety risks of concern such as leaving the water or gas on.  In order to allow for basic quality of life.  The patient needed reminders to eat, bathe, and take medications.

Based on the above, the insurer's denial must be overturned. 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); 12 hours per day- 7 days per week; 12 hours per day 7 days per week- for a total of 168 hours per week (split-shift) is substantiated.