Diagnosis: Osteoarthritis
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services: 8 Hours per Day, 7 Days per Week - Total Amount of 56 Hours per Week.
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 8 Hours per Day, 7 Days per Week - Total Amount of 56 Hours per Week.
The health plan's determination is overturned.

The patient is a male with past medical history of gout, osteoarthritis, urinary incontinence, hypothyroidism, chronic kidney disease, hyperlipidemia, hypertension, and coronary artery disease who had been assigned CDPAP (Consumer Directed Personal Assistance Program) services based on an assessment that assessed the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and managing medication. With tasks of shopping, transportation, and dressing upper/lower body, the patient was assessed at limited assistance while supervision with tasks of managing finances, stairs, bathing, personal hygiene, walking, and locomotion. With task of phone use, the patient was assessed at set up assistance while independent with tasks of transfer toilet, toilet use, bed mobility, and eating.

Consumer Directed Personal Assistance Program (CDPAP) Services: 8 Hours per Day, 7 Days per Week - Total Amount of 56 Hours per Week is medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased CDPAP services. The patient previously had more hours as part of a mutual case with his wife but she had since expired. The patient's son was no longer able to provide informal help due to his own medical conditions. The denial incorrectly stated that the patient required set up help with transfer toilet but the recent assessment stated he required supervision. The recent assessment also noted increased assistance needs with tasks of shopping, bathing, personal hygiene, and transfer toilet. The plan incorrectly assumed the patient had informal help outside of the hours of CDPAP services. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs when the patient has no informal help. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, CDPAP services 8 hours/day, 7 days/week, to total 56 hours/week are medically necessary for this patient.