Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory system
Treatment: Home Health Care

Diagnosis: Respiratory System-COPD-BiPap
Treatment: Home Health Care- Increase in consumer Directed Personal Assistance Program services. (CDPAP)
The health plan denied an increase in CDPAP services as not medically necessary. The reviewer has overturned in whole the health plans determination. 

The patient has a past medical history of asthma, chronic obstructive pulmonary disease (COPD), osteoarthritis, obstructive sleep apnea on bi-level positive airway pressure (BiPAP) therapy, seizure disorder, gastroesophageal reflux disease (GERD), hyperlipidemia, hypertension, depression, and urinary incontinence who had been assigned consumer directed personal assistance program (CDPAP) services 30 hours/week. There was a request to increase services to 60 hours/week. The insurer sent final adverse determination denial notice denying request to increase CDPAP services stating the patient lived alone and had supportive family and the patient should speak to her medical providers about pain management options to help her as well as recommendations for physical and Occupational Therapy. The denial also stated the patient should utilize incontinence supplies to help keep her comfortable and dry and the patient should utilize home delivered meals 4 days/week. In addition, the denial stated the patient could schedule her current hours to meet her needs by splitting or adjusting. The patient's allergist provided a letter stating the patient had severe asthma and allergic rhino conjunctivitis and the patient has been medically advised to avoid mold exposure due to worsening asthma symptoms that could be potentially life-threatening. The patient's pulmonologist provided another letter stating the patient had fatigue from COPD, required assistance with using her CPAP machine and nebulizer, required assistance with ambulation/locomotion, required assistance with transfers, and required an increase in home care services to assure the patient could safely complete her activities of daily living. The patient's primary provider noted the patient experienced fatigue when walking due to her COPD and must rest often, had difficulty opening bottles easily or dressing or bathing herself due to limited range of motion from osteoarthritis, needed assistance with ambulation/locomotion as she was unable to walk independently, required assistance with reminding to take medications and making medical appointments, and in the event of emergency the patient did not have any family members that could be with her in the emergency room. The patient's granddaughter moved and the patient no longer had informal support during the weekends and evenings.

There is documentation from the patient's primary care provider as well as pulmonologist of medical necessity of increased CDPAP services. The plan's own assessment noted the patient required extensive assistance with walking, locomotion, transfer toilet, and toilet use. The patient therefore has unpredictable and unscheduled care needs that span a continuum of time and the plan failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's granddaughter was no longer able to provide informal support and the patient lived alone. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAP services was not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Considering clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 60 hours/week are medically necessary for this patient. 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 her own home.