Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Home Health Services

Diagnosis: Parkinson's Disease, Osteoarthritis
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week
The determination is overturned.

This is a male patient with a past medical history of Parkinson's disease with a deep nerve stimulator, vitamin B12 deficiency, hyperlipidemia, osteoarthritis, urinary incontinence, fecal incontinence, restless leg syndrome, and insomnia who had been assigned Consumer Directed Personal Assistant Program (CDPAP) services 12 hours/day, 7 days/week, based on a video assessment. Notes from the assessment stated the patient lived alone and had informal support from his daughter. The patient's primary care physician (PCP) noted despite medications the patient was left with periods of extreme rigidness and tremor and the patient's condition had deteriorated in the preceding months. In addition, the patient's PCP noted the patient required an overnight aide as the patient was a fall risk and attempting to ambulate or transfer on his own put the patient's own health at risk. 
The patient underwent another assessment assessing the patient at the same level of assistance as the video assessment. Notes from the assessment stated the patient needed a brain device battery replaced, lived in a 1-bedroom apartment with his wife, and the patient was unable to get up and out of bed on his own or change his position in bed at night. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week.
The requested services are medically necessary.
There is documentation from the patient's medical provider and the plan's assessment of worsening physical functioning and increased assistance needs due to the progression of Parkinson's disease. The patient's medical provider documented medical necessity of increased CDPAP services, stating the patient required turning and repositioning overnight, the patient required assistance with toileting and incontinence care in the overnight hours, and the patient required assistance with frequent medication administration, including the overnight hours. Overnight care logs document assistance needs with turning and repositioning, transfer toilet, toilet use, and medication administration in the overnight hours at least every 1-1/2 hours. The patient requires at least extensive assistance with all activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) except for managing finances and eating and the insurer did not document a plan to meet the patient's needs in the overnight hours. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Personal care 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 his own home.