Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke. 
Treatment: Consumer directed personal assistance service (CDPAS) at 45 hours per week. 

The insurer denied consumer directed personal assistance service (CDPAS) at 45 hours per week. 

The determination is upheld. 

The patient is requesting consumer directed personal assistant services (CDPAS) at 45 hours per week. The plan approved 28 hours per week for 26 weeks. 
According to the plan, 45 hours/week was declined due to a lack of medical records demonstrating medical necessity. According to the plan, medical records were not received after they were requested. A separate document states that the nursing assessment done reports the patient's care needs can be met in 28 hours a week. 
According to the patient's statement, he disagrees with this determination stating that he has medical conditions that prevent him from being unable to do daily activities such as cooking and cleaning. He is also unable to go to his doctor's appointments or pharmacies for his medications. 
A physician's order for these services was provided. It states the patient has a history of a left cerebellar stroke and also reports a history of type 2 diabetes with neuropathy. The patient has weakness and chronic pain. The patient's condition is reported to be stable. The patient needs assistance with medication management. His ambulation is impaired. He requires assistive devices to ambulate. The patient is unable to self administer medications. There is a note stating that the family assists with this. 
Additionally the physician's order notes the patient has right-sided weakness secondary to a stroke. He has poor range of motion and he is slow to communicate. 
Additional documentation states that the patient needs maximal assistance with bathing and requires assistance with bathing, transferring in and out and drying off. The patient has total dependence for personal hygiene. He needs total assistance with brushing his teeth, shaving, nail care, hair care. He needs extensive assistance with dressing, upper body; needs maximal assistance with dressing, lower body; needs extensive assistance with walking; needs extensive assistance with stairs; needs extensive assistance with toilet transfer; needs assistance with rising from a sitting position and lowering to a sitting position: needs limited assistance with bed mobility and transferring; is totally dependent for meal preparation. He has total dependence for wound care and cleaning; total dependence for laundry; total dependence for managing finances. The family addresses this however. He needs maximal assistance with medication management. He relies on family for transportation. This is the extent of the documentation provided.
At issue is the medical necessity of consumer directed personal assistance service (CDPAS) at 45 hours per week. 

The requested services are not medically necessary. 

With the information made available, the 28 hours/week is justified. Reviewing the documentation demonstrating the patient's limitations and assistance needs, the hours per day and days per week; in addition to the numbers of times per day, appears to be reasonably appropriated. Adding all of these together gives 26 hours in a given week. The patient does have limitations secondary to his chronic medical conditions, namely stroke. However, documentation provided by the family and his medical team do not expand on his circumstances nor expand on why his needs are more than what was provided/improved. Therefore, the requested services are not medically necessary.