Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety, hypertension, coronary artery disease, depression, and cancer. 
Treatment: Consumer Directed Personal Assistance Services 54 Hours per Week. 

The insurer denied the Consumer Directed Personal Assistance Services 54 Hours per Week. 

The denial is upheld. 

This female patient has conditions including anxiety, hypertension, coronary artery disease, depression, and cancer.  She is appealing denial of increase consumer directed personal assistance services (CDPAS) from 40 hours per week to 54 hours per week. The plan approved increase to 42 hours per week.  The patient lives with her son. 

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, managing finances, and shopping; extensive assistance with managing medication, phone use, stairs, transportation, and bathing; limited assistance with personal hygiene, dressing, walking, locomotion, and toileting; independent with bed mobility; and supervision with eating.  She ambulates using a cane and furniture.  She has occasional urinary incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed previously, cognition has deteriorated from modified independent and there has been a decline in functioning with meal preparation, managing finances and medications, personal hygiene, walking, locomotion, and toilet transfer. 

A statement from the provider notes the patient has new memory loss and several chronic medical condition.  The provider is requesting an additional two hours of assistance. 

No, the proposed treatment is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. 

This patient has multiple chronic conditions.  She is appealing denial of increase consumer directed personal assistance services (CDPAS) from 40 hours per week to 54 hours per week. The plan approved increase to 42 hours per week.  Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with meal preparation, housework, managing finances, shopping, managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing, walking, locomotion, and toileting.  Compared to Uniform Assessment System (UAS) evaluation completed previously, cognition has deteriorated from modified independent and there has been a decline in functioning with meal preparation, managing finances and medications, personal hygiene, walking, locomotion, and toilet transfer.  She has occasional urinary incontinence.  The appeal statements indicate the patient has several chronic conditions and new memory loss.  This patient's needs for assistance with activities of daily living (ADLs) and personal care do not require additional hours.  The assistance can be scheduled to meet the patient's needs.  Consumer directed personal assistance services are not indicated to manage medical conditions or when no services are being performed.  The approved increase consumer directed personal assistance services from 40 to 42 hours per week is appropriate and medically necessary to meets the patient's needs for assistance with activities of daily living (ADLs) and personal care.  The proposed increase in consumer directed personal assistance services to total 54 per week is not medically necessary. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.