Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dandy-Walker syndrome, Down syndrome, asthma, congenital heart disease
Treatment: Increase Consumer Directed Personal Assistance
Services For a Total of 105 Hours Per Week
The insurer denied: Increase Consumer Directed Personal Assistance Services For a Total of 105 Hours Per Week
The denial is overturned.

The patient is a school aged male child with medical history significant for Dandy-Walker syndrome, Down syndrome, asthma, congenital heart disease (atrial septal defect,
ventriculoseptal defect status post repair, pulmonary hypertension, mitral valve regurgitation requiring valve repair, patent ductus arteriosus status post closure), two cerebral infarcts with resultant right-sided weakness, duodenal atresia status post repair with two colostomy openings on his abdomen (bag changed three times a day), gastroesophageal reflux disease with gastrostomy dependence, hydrocephalus status post ventriculoperitoneal (VP) shunt placement, laryngomalacia, laryngeal/pharyngeal cleft status post laryngoplasty, obstructive
sleep apnea status post tonsillectomy and adenoidectomy dependent on bi-level positive airway pressure (BiPAP) at night, and severe intellectual disability with developmental delay. He takes some purees by mouth with therapy. He has undergone PEG (percutaneous endoscopic gastrostomy) tube placement and left cryptorchidism status post orchiopexy within the past year. He has history of Clostridium difficile infection twice and was hospitalized in the pediatric intensive care unit (PICU) following inhalation injury from a fire in the house. He requires daily asthma prevention with budesonide, levalbuterol, and montelukast. He is non-verbal and non-ambulatory. The patient requires extensive assistance with upper and lower body dressing, transfers, bathing, personal hygiene, bed mobility,
positioning, walking, locomotion (he is bed-bound and
wheelchair dependent). He is incontinent of bowel and bladder.
The patient lives with his mother in a shelter. His mother is the primary caregiver, the father is not involved. His mother has reportedly worsening health, persistent hypertension, requiring a surgical procedure on her shoulder. A note was submitted by her doctor stating that the mother has a left shoulder labral tear, and she is not allowed to work, with no heavy lifting, no pushing, no pulling. She underwent arthroscopy in 7 months ago. She may also require left wrist surgery. The child does not attend school because of distance to the school and transportation time. For 6 months the patient was approved for consumer directed personal assistance services (CDPAS) 42 hours/week. The request is for 105 hours/week seven days a week as the mother recovers from her surgical procedures. 

The requested Increase Consumer Directed Personal Assistance Services For a Total of 105 Hours Per Week is medically necessary.

The requested 105 hours/week of Consumer Directed Personal Assistance Services are medically necessary and appropriate.
This young male child has a number of disabilities and medical conditions as a result of and in addition to his Dandy-Walker syndrome and Down syndrome. He has significant anatomic cardiac and gastrointestinal abnormalities. He has pulmonary challenges with his asthma, and he has a ventriculoperitoneal shunt, colostomy, gastrostomy, and requires bi-level positive airway pressure during sleep. He is fully dependent for all activities of daily living. He is non-verbal and non-ambulatory. He is unable to transfer independently. His mother is not able to
manage his physical needs because of her musculoskeletal limitations. The additional hours remain medically necessary until the mother can be cleared to provide for the patient's care. The requested duration is reasonable as an estimate. The duration is dependent upon her ability to resume his care.