Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Consumer Directed Personal Assistance Program (CDPAP): CDPAP: 12 hours per day - 7 day(s) per week -a total of 84 hours per week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP): CDPAP: 12 hours per day - 7 day(s) per week -a total of 84 hours per week.
The determination is overturned in part.

This is a female patient with a medical history notable for osteoarthritis with pain in the hands and legs. The patient is approved for 2 hours per day, 7 days per week of consumer directed personal assistance program services. The patient and her care team requested an increase to 12 hours per day, 7 days per week for a total of 84 hours per week, and this request was denied by the health plan.
The patient's primary care physician provided a letter of support for this appeal. The letter states that the patient has had procedures and has weakness of both extremities. The letter states that she would "benefit from 12 hours per day." There is no discussion regarding any currently unmet personal care needs.
A Uniform Assessment System (UAS) was completed. For her instrumental activities of daily living, the patient requires total dependence for housework. She requires maximal assistance for shopping and stairs. She requires extensive assistance for medications and meal preparation. For her activities of daily living, she requires extensive assistance for hygiene and dressing upper body. She requires limited assistance for bathing, dressing lower body, walking, locomotion, and toilet transfer. She is independent for toilet use, bed mobility, and eating. She is frequently incontinent of urine and is continent of stool. A task tool associated with the assessment recommended 4 hours per day, or 28 hours per week to address her personal care needs. They also recommended two days of social daycare per week with 7 hours per week of additional assistance. Compared to a prior assessment, the patient showed a slight decline in functional status. The prior assessment recommended 14 hours per week to address her personal care needs. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP): CDPAP: 12 hours per day - 7 day(s) per week -a total of 84 hours per week.

In part. The requested health service of Consumer Directed Personal Assistance Program (CDPAP): CDPAP: 12 hours per day - 7 day(s) per week-a total of 84 hours per week has not been demonstrated to be medically necessary for this patient. 4 hours per day, 7 days per week for a total of 28 hours per week is medically necessary for this patient.
The patient has personal care needs which primarily revolve around instrumental activities of daily living and are a result of pain and stiffness from arthritis in the upper extremities. She requires some assistance with dressing and hygiene as well. The task tool recommends 4 hours per day for the patient. The plan should provide the increased number of personal care hours as recommended by the task tool as a reflection of her declining functional status.
There is insufficient evidence that the patient requires 12 hours per day of personal care services as requested. There is no evidence of currently unmet personal care needs. There is no documentation which would demonstrate that the recommended increase to 4 hours per day, 28 hours per week of personal care assistance would be insufficient to provide for her personal care needs.