Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive Dementia.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 112 Hours per Week.

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 112 hours per week. The denial is modified. 

This is an elderly female with chronic medical problems, including progressive dementia. The patient was a nursing facility resident on the date of the more recent assessment. Her daughter is the paid home care provider. Upon discharge from the nursing facility, the patient will reportedly live with her two adult sons in a 3-bedroom apartment. In the Final Adverse Determination letter, the insurer indicated the plan initially approved home care / personal care consumer directed personal assistance services (CDPAS) for 20 hours per week. The plan's approval increased to home care / personal care CDPAS for 30 hours per week. The patient requested an increase to CDPAS for 112 hours per week, leading to an external review.  

The patient's cognitive skills are described as "severely impaired." The patient's ability to perform much of her Instrumental Activities of Daily Living (IADL) tasks, including meal preparation, ordinary housework, and shopping, reportedly varies from maximal assistance to total dependence. The patient reportedly requires extensive assistance for bathing, personal hygiene, dressing, toilet transfer/use, locomotion, eating, toilet transfer/use, and ambulation (However, the patient independently wanders at night).   Bed mobility is independent. The patient is reportedly incontinent of the bladder and occasionally incontinent of the bowel. There have been no reported falls over the prior 90 days. The patient's ability to perform activities of daily living and self-sufficiency have reportedly declined and deteriorated, respectively, over the last 90 days. The patient's cognitive and functional abilities have declined compared to the prior assessment.

The patient's condition and functional deficits are not at a level or unpredictable as to require the requested CDPAS 112 hours/week. This physician would agree the patient may benefit from additional monitoring for safety, particularly due to her reported wandering, weakness, and fall risk. However, PAS hours are approved primarily to provide hands-on assistance for completing IADL/ activities of daily living (ADL) tasks when no one else is available to assist. Given her decreased cognition, functional ability, and substantial functional impairments, additional hours are warranted. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by increasing CDPAS to 70 hours/week. The patient also benefits from other adults living in the home with shared household responsibilities.

CDPAS 112 hours/week is not medically necessary from a physical medicine and rehabilitation perspective.  However, increasing CDPAS to 70 hours/week is medically necessary.  

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably, with sound medical judgment, and in the patient's best interest. The medical necessity for consumer directed personal assistance services (CDPAS) 112 hours per week services is not substantiated. However, increasing CDPAS to 70 hours/week is medically necessary.