Appeal type: Medical necessity
Decision: Overturned

Diagnosis: generalized arthritis, coronary artery disease, congestive heart failure (CHF), hypertension, asthma, angina, vertigo and dizziness

Treatment: consumer directed personal assistance program (CDPAP) services for a total amount of 84 hours per week

The insurer denied coverage for consumer directed personal assistance program (CDPAP) services for a total amount of 84 hours per week

The denial is modified

 
This is an adult with chronic medical problems including generalized arthritis, coronary artery disease, congestive heart failure (CHF), hypertension, asthma, angina, vertigo and dizziness.   The patient lives alone.  His son assists him with some instrumental activities of daily living (IADL) and activities of daily living) ADL and is dedicated to his father, but his time is limited due to other obligations. The patient has had no falls or hospitalizations in the last 90 day.

The New York State (NYS) Uniform Assessment was reviewed and referenced. The patient's cognitive function is described as modified independent with no memory loss. He needs extensive assistance for weight bearing and ambulation with a reported recent decline.  He cannot easily use his left arm for wheeling due to the limited range of motion from a previous accident. He needs maximal  assistance for lower body dressing, bathing, weight bearing, toileting and toilet transfer. He also needs maximal assistance for shopping, meal preparation and housework,  He can call for emergency assistance independently. The hours approved assist him with the tasks listed above and with personal hygiene. 

His physician reports a recent decline in ambulation with increased shortness of breath and bilateral  leg edema. Entresto and Lasix have been added to his regimen.  The addition of Lasix has increased his urinary frequency and incontinence necessitating frequent diaper changes.  This finding can also increase his risk for falls. The risk of falling can also be  increased due to his vertigo and dizziness.  

Personal assistance program (CDPAP) services are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance. 
 
Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained with 56 hour of hours/week of personal assistance program (CDPAP) services. He has the means for emergency assistance and can use the emergency devices reliably. 
 
The carrier's decision to deny an increase in personal assistance program (CDPAP) services  should be modified to allow for 56 hours per week (7x 8 hours per day).  These hours can be used flexibly to best meet the patient's need.

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 program (CDPAP) services for a total amount of 84 hours per week services is not substantiated. However, personal assistance program (CDPAP) services  should be modified to allow for 56 hours per week (7x 8 hours per day).