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202110-142699

2021

Healthfirst Inc.

Medicaid

Mental Health

Home Health Care

Medical necessity

Upheld

Case Summary

Diagnosis: Mental Health.
Treatment: Home Health Care.
The insurer denied consumer directed personal care assistance services.
The denial is upheld.

The patient is a male with past medical history of major depressive disorder, specified abnormal immunological finding in serum, gastroesophageal reflux disease (GERD), tobacco abuse, vitamin D deficiency, hypertriglyceridemia, and tachycardia who requested Consumer Directed Personal Assistance Program (CDPAP) services. The patient underwent an assessment tool assessing him at extensive assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, shopping, transportation, and equipment management while supervision with task of bathing. The patient was assessed at set up only with task of phone use and independent with tasks of stairs, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The assessment noted the patient had memory problems, the patient lived with his mother, the patient's mother was primary caregiver, and the patient had 72 hours of informal care and active monitoring during the last 3 days. The insurer sent final adverse determination notice denying request for CDPAP services. The denial stated the patient was able to perform activities such as toileting and personal hygiene and could walk on his own. The denial also stated the M11Q signed by the patient's doctor reflected chronic and other conditions that do not impact the patient's ability to perform daily activities.

The health plan's determination is upheld in whole.

The consumer directed personal care assistance services (CDPAS) are not medically necessary for this patient.
The patient does not have assistance needs of at least limited assistance with physical maneuvering with more than two activities of daily living. The patient did not require more than 8 hours of assistance with tasks per week. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services are not medically necessary for this patient.

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