Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, Lymphedema

Treatment: Consumer directed personal assistance services (CDPAS) 82 hours per week over 7 days a week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 82 hours per week over 7 days a week.

The denial is modified.

This is a patient with chronic medical problems diabetes, atrial fibrillation and lymphedema. The patient lives with their spouse who is supportive of their care. The patient's family reportedly provides informal care on the weekends.  The insurer decreased their previously approved Consumer Directed Personal Assistance Services Program (CDPAS) 82 hours/week to 28 hours/week, leading to an external review.   

The Uniform Assessment System (UAS) report is reviewed.  The patient's cognitive skills are described as independent.  The patient reportedly requires maximal assistance to total dependence for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing and lower body dressing.  Limited assistance is reportedly needed for personal hygiene, upper body dressing, locomotion, toilet transfer/use and ambulation.  The patient is independent for eating and bed mobility. The patient is also fully continent of bowel and bladder.  

There has been no change in the patient's activities of daily living (ADL) status, self-sufficiency or reported falls over the prior 90 days. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested CDPAS (Consumer Directed Personal Assistance Services) 82 hours/week. The letter from the patient's treating nurse practitioner (NP) was reviewed.  The NP indicates the patient "has a significant history of serious medical complications and it's medically necessary for him to have the assistance of 80 hours of homecare service per week due to his complex needs."  The NP does not provide their associated treatment notes or specifically describe the patient's "serious medical complications" that reportedly require the requested amount of home care services. The care log and associated summary was also reviewed.  The hours appear inflated, e.g. (for example), 4 hours/day for "Doctor appointments, church, library, shopping etc.," 2 hours/day for "cleaning, light housekeeping laundry" and 2 hours/day for "lymph pump boot assistance, physical therapy exercise and cane walking program."  

This physician would agree that the patient may benefit from monitoring for safety; particularly due to the patient's decreased mobility and falls risk.  However, CDPAS (Consumer Directed Personal Assistance Services) for companion care or safety supervision without the direct provision of ADL (activities of daily living) task assistance is not a covered service.  Based on the enclosed documents reviewed, this physician recommends increasing CDPAS to 6 hours/day, 7 days/week for a total of 42 hours/week.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based). 

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 consumer directed personal assistance services (CDPAS) 82 hours per week over 7 days a week services is not substantiated. However, increasing CDPAS to 42 hours/week over 7 days is medically necessary.