Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer
Treatment: Increase Consumer Directed Personal Assistance 
Services (CDPAS) (to 7 days per week, 8 hours per day for a total of 56 hours per week)
The insurer denied Increase Consumer Directed Personal Assistance Services (CDPAS) (to 7 days per week, 8 hours per day for a total of 56 hours per week).
The denial is overturned.

The patient is an adult female with a history of general debility due to lymphedema, neuropathy, breast cancer, knee osteoarthritis. The request was for increase in Consumer Directed Personal Assistance Service to 56 hours per week (8 hours per day, 7 days per week) based on Uniform Assessment System (UAS) of 2 months ago as against the previously approved 31.5 hours per week (4.5 hours per day, 7 days per week). She lives in an apartment alone. The health plan denied coverage of the request as not medically necessary, noting that the patient is alert; oriented to person, place, and time with forgetfulness; self-directing; able to ambulate; transfer and use the toilet with assistance; use of assistive device (walker), and able to feed herself. The additional hours requested are because of the patient's chronic medical conditions. She has 
decreased motor function, limited range of motion, and reduced mobility while requiring assistance for most activities. Also, she suffers from lymphedema status post breast lumpectomy due to right breast cancer, is a high fall risk, needs administration of medications/meals three times daily, self-care, household chores, shopping, physician appointments. A review of the records showed that the patient has multiple chronic medical conditions, such as lymphedema status post right breast lumpectomy, bilateral knee osteoarthritis, depression, ataxic gait, insomnia, urinary incontinence, high fall risks. The patient's Uniform Assessment System (UAS) evaluation of 2 months ago showed that she requires extensive assistance with meal preparation, phone use, shopping, bathing; maximum assistance with housework, walking and locomotion; limited assistance with managing finances, managing medications, personal hygiene, upper body dressing, toilet use, bed mobility, eating. Her family support is very limited, as she lives alone in a two-bedroom apartment on the first floor with an elevator.

The requested health service is medically necessary.

Based on Uniform Assessment System (UAS) evaluation of 2 months ago, the patient requires extensive assistance with meal preparation, phone use, shopping, bathing; maximum assistance with housework, walking and locomotion; limited assistance with managing finances, managing medications, personal hygiene, upper body dressing, toilet use, bed mobility, eating. The patient's family support is very limited, as she lives alone in a two-bedroom apartment on the first floor with an elevator. The reason for denial by the health plan as noted in the clinical information above, does not align with her disability features as noted in the Uniform Assessment System evaluation of 2 months ago as stated above. Therefore, based on Uniform Assessment System evaluation of 2 months ago, the requested increase in community directed personal assistance services to 56 hours per week (8 hours per day, 7 days per week) is medically necessary. The patient requires extensive assistance with meal preparation, phone use, shopping, bathing; maximum assistance with housework, walking, locomotion; and limited assistance with managing finances, managing medications, personal hygiene, upper body dressing, toilet use, bed mobility, eating.