Diagnosis: Chronic neck and back pain.
Treatment: Personal Care Worker Service-via CDPAS (Consumer Directed Personal Assistance Service) hours- 7 hours x 7 days a week, total 49 hours per week.

The insurer denied Personal Care Worker Service-via CDPAS hours- 7 hours x 7 days a week, total 49 hours per week. The determination is overturned.

The patient is a male with a past medical history (PMH) of left eye blindness, glaucoma of both eyes, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus (T2DM), coronary artery disease (CAD), chronic back pain and chronic neck pain. His primary care doctor recommended consumer directed personal assistance services increase to 49 hours per week instead of 35 hours per week. At issue is the medical necessity of the requested health service/treatment of Personal Care Worker Service via Consumer Directed Personal Assistance Services (CDPAS) hours- 7 hours x 7 days a week, total 49 hours per week.

The health plan, in its determination of medical necessity, acted reasonably. However, the health plan did not act in the best interest of the patient. This is a severely visually impaired patient who suffers from rheumatoid arthritis. The patient is heavily dependent on dressing himself, bathing, going to the bathroom and using the toilet. Patients with rheumatoid arthritis are at a higher risk of fracture than the typical population and require closer monitoring. This patient has had a fall in the past 12 months. In addition, the patient has 10 minutes to eat per meal. It is not reasonable to expect this patient to eat a meal in 10 minutes. He should also be ambulatory for more than 20 minutes per day. Given his history of diabetes, he should be walking 20-30 minutes per day with assistance. While the patient gets help from family and friends for activities of daily living, it is not reasonable to have this burden placed on them, especially when they have no training in specifically caring for patients like this.