Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heart disease, diabetes and lung cancer

Treatment: home care / consumer directed personal assistance services (CDPAS) 24 hours per day (live in)

The insurer denied coverage for home care / consumer directed personal assistance services (CDPAS) 24 hours per day (live in)

The denial is modified
 

The patient is an elderly female with chronic medical problems including heart disease, diabetes and lung cancer. She lives alone in a private residence. The patient is approved for home care / consumer directed personal assistance services (CDPAS) 56 hours per week. The request is for home care / consumer directed personal assistance services (CDPAS) 24 hours per day (live in) that was denied by the insurer, leading to an external review.

According to the Uniform Assessment System (UAS) report the patient's cognition is described as minimally impaired. However, she is reportedly unable to dial 911 in an emergency or utilize a Personal Emergency Response System (PERS). She reportedly requires maximal assistance to total dependence for performing much of her Instrumental Activities of Daily Living (lADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires extensive assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation (however, she was observed by nurse assessor ambulating short distances with a walker). She reportedly requires limited assistance for personal hygiene and upper body dressing. The patient is independent for bed mobility and eating. She reports being frequently incontinent of bladder and continent of bowel. There has been no reported change regarding her ability to perform activities of daily living, self-sufficiency or reported falls over the prior 90 days. The patient's functional ability has declined when compared to the prior UAS report.

Based on the case notes, The patient does not have functional needs at a level or unpredictable as to require the requested home care / consumer directed personal assistance services (CDPAS) 24 hours per day (live in). The patient's treating physician, submitted a letter describing her clinical condition; noting "patient often wakes up at night, and if left without supervision at night might sustain falls and injuries." The doctor requested an evaluation for the provision of "24 hours 7 days home care services to ensure patient's safety and stability at home." The doctor does not include the associated treatment notes to support his claim of the patient's reported functional incapacity.

Based on the documents reviewed, The patient's functional needs are more appropriately provided and maintained by increasing home care / consumer directed personal assistance services (CDPAS) to 10 hours/day, 7 days/week; total 70 hours/week. The patient may also have the option of restructuring and flexibly using the 70 Personal Aide Service hours weekly (perhaps 2 shifts) to better maintain and meet her functional needs.

Based on the above, the insurer's denial must be modified. 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 home care / consumer directed personal assistance services (CDPAS) 24 hours per day (live in) services is not substantiated.  However, increasing home care / consumer directed personal assistance services (CDPAS) to 10 hours/day, 7 days/week; total 70 hours/week is medically necessary.