Appeal type: Medical necessity
Decision: Overturned

Diagnosis: multiple sclerosis and resultant quadriplegia

Treatment: increase in Consumer Directed Personal Assistance Services from 7 days per week, 8 hours per day; 56 hours per week to 7 days per week 16 hours per day; 112 hours per week

The insurer denied coverage for increase in Consumer Directed Personal Assistance Services from 7 days per week, 8 hours per day; 56 hours per week to 7 days per week 16 hours per day; 112 hours per week

The denial is modified.

 
This is an adult with multiple sclerosis and resultant quadriplegia. The patient requested an increase in Consumer Directed Personal Assistance Services (CDPAS) from 7 days per week, 8 hours per day; 56 hours per week to 7 days per week 16 hours per day; 112 hours per week. The insurer approved CDPAS 7 days per week, 9 hours per day; 63 hours per week. Under review are the denied CDPAS 7 days per week, 7 hours per day; 49 hours per week.

The patient's cognitive skills are described as "Modified independent." He is reportedly totally dependent for completing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, upper body dressing, toilet transfer/use and ambulation. Extensive assistance is reportedly needed for lower body dressing. He reportedly requires limited assistance for personal hygiene, eating, bed mobility and locomotion. He uses a motorized wheelchair for mobility. The patient uses a catheter for bladder management and reportedly occasionally incontinent of bowel. 

There has been no change in his activities of daily living (ADL) status, level of self-sufficiency or reported falls over the prior 90 days. His functional ability has also not significantly changed when compared to the UAS report. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested CDPAS 112 hours/week. The patient may benefit from monitoring for safety; particularly due to his decreased mobility and falls risk. CDPAS for companion care or safety supervision without the direct provision of ADL task assistance is not a covered service. However, after reviewing the case notes and letters from his treating physician documenting the patient' progressive clinical condition, vision and hearing impairments; increasing CDPAS 12 hours/day, 7 days/week, for a total of 84 hours/week is clinically supported and medically necessary. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing CDPAS 12 hours/day, 7 days/week, for a total of 84 hours/week.

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 an increase in Consumer Directed Personal Assistance Services (CDPAS) from 7 days per week, 8 hours per day; 56 hours per week to 7 days per week 16 hours per day; 112 hours per week services is not substantiated. However, increasing CDPAS from 7 days per week, 8 hours per day; 56 hours per week to 7 days per week 12 hours per day; 84 hours per week is medically necessary.