Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic right-sided low back pain with right-sided sciatica. 
Treatment: Increase in consumer directed personal assistance service (CDPAS) hours to 112 hours. 
The insurer denied coverage for the increase in consumer directed personal assistance service (CDPAS) hours to 112 hours.  
The denial is modified. 

This is an adult with a past medical history including type two diabetes, hypertension, hypercholesterolemia, vitamin B12 deficiency and osteoporosis. The patient was brought by their son for evaluation of increasing pain in the lower back radiating down the right leg. The patient had also fallen a few times because of their legs suddenly giving out. The patient reports frequency and burning sensation on urination. A physical examination revealed tenderness over the lumbosacral spine and right sacroiliac (SI) joint. Movement of the spine was painful. The patient was unsteady on their feet and could not perform heel or toe walking. The primary diagnosis was chronic right-sided low back pain with right-sided sciatica. The plan was for a referral to physical therapy. The patient was advised to use a rollator walker at all times for prevention of falls. The patient resides with their son, daughter-in-law, and grandchildren. All lifestyle choices and decisions are made by the son on behalf of the patient to ensure the patient's health and safety. The patient had been receiving 77 hours of consumer-directed personal assistance services (CDPAS). The insurer decreased the hours from 77 hours per week to 34 hours per week. The patient is requesting 112 CDPAS hours, which is under review. 

"Many older people live at home, often with complex and chronic health and social care needs. Integrated care programs are increasingly being implemented as a way to better address these needs. To support older people living at home, it is also essential to maintain their safety. Integrated care programs have the potential to address a wide range of risks and problems that could undermine older people's ability to live independently at home. The aim of this scoping review is to provide insight into how integrated care programs address safety risks faced by older people living at home - an area that is rather underexplored. The need to address social and environmental risks is becoming increasingly important given the growing number of people receiving care and support at home" (3). 

At the time the Uniform Assessment System (UAS) was completed, the patient was receiving 77 hours of consumer directed personal assistance services (CDPAS). The patient currently lives with caregivers including a son, who assists with the patient's activities of daily living (ADLs) and other needs. The patient required maximal to full dependence for all instrumental activities of daily living (IADLs). The patient required total dependence for lower body dressing. Maximal assistance was needed for bathing and upper body dressing. Extensive assistance was needed for walking/locomotion, transfer toilet. The patient was independent/setup help only for toilet use, bed mobility and eating. The patient's ADL status was reported to have declined and overall self-sufficiency had deteriorated over the past 90 days. The patient was medically stable, without any acute medical conditions or recent surgeries/hospitalizations. While there was no documentation provided for review to support why an additional 35 personal assistance hours are required, the submitted documentation did not support a decrease in services. 

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. 

While the medical necessity for an increase in consumer directed personal assistance service (CDPAS) hours from 34 hours to 112 hours is not substantiated, 77 hours of CDPAS is medically necessary.