Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease; osteoarthritis
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services to 24 hours/day (live in)
The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) Services to 24 hours/day (live in).
The denial is overturned.

The patient is a male who has medical conditions including Parkinson's disease and osteoarthritis. The patient lives alone. Denial of increase in Consumer Directed Personal Assistance Program (CDPAP) Services to 24 hours/day, live in, is being appealed. He has been approved for 42 hours/week.

UAS (Uniform Assessment System) evaluation completed shows modified independent cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, bathing, toileting, lower body dressing, and toileting; extensive assistance with walking, locomotion, personal hygiene, upper body dressing and bed mobility; and limited assistance with phone use and eating. He has a foley for urinary retention. He is infrequently incontinent of bowel. Compared to UAS (Uniform Assessment System) evaluation completed previously, there is a decline cognition and in functional status with lower body dressing, toileting, bathing, walking, locomotion and eating.

An appeal letter notes the patient has complications of Parkinson's disease with a progressive decline affecting ability to perform ADLs (activities of daily living). The letter notes the patient has difficulty turning in bed and needs repositioning throughout the night with straightening of catheter. An appeal letter notes the patient is unable to perform ADLs (activities of daily living) independently. The letter notes the patient is a fall risk and requires 24 hour/day care. A letter dated from his PCP (primary care provider) notes his functional capacity has declined over the last few years. The letter notes the patient needs assistance with ADLs (activities of daily living) and needs repositioning throughout the night.

Yes, the Increase Consumer Directed Personal Assistance Program (CDPAP) Services to 24 hours/day (live in) is medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase Consumer Directed Personal Assistance Program (CDPAP) Services to 24 hours/day, live in, is being appealed. The patient has been approved for 42 hours/week.

This patient has multiple chronic conditions including Parkinson's disease with complications. Per UAS (Uniform Assessment System) evaluation completed, the patient has modified independent cognition and requires assistance with all ADLs (activities of daily living) and personal care needs. He has a foley and bowel incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there is a decline cognition and in functional status with lower body dressing, toileting, bathing, walking, locomotion and eating. Appeal letters show the patient's physical functioning has declined. They note the patient requires assistance 24 hours/day, including repositioning throughout the night. This patient has significant needs for assistance with ADLs (activities of daily living) during day and night. The assistance needed along with repositioning, cannot be met with the currently approved CDPAP (Consumer Directed Personal Assistance Program) 42 hours/week. The proposed increase CDPAP (Consumer Directed Personal Assistance Program) to 24 hours/day, live in is medically necessary to meet this patient's needs for assistance as noted above.