Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incontinence
Treatment: Increase in Consumer Directed Personal Assistance Services to 84 hours a week 
The insurer denied: Consumer Directed Personal Assistance Services to 84 hours a week 
The denial is: Upheld.

The patient is a female with medical history notable for unsteady gait, sciatica, and incontinence. The patient was approved for 20 hours per week of personal care services (consumer directed personal assistance services "CDPAS"). The patient and her care team requested an increase to 84 hours per week, and this request was partially denied by the insurance company; they did approve an increase to 45 hours per week. This denial is the subject under review.

The patient's physician provided a letter of medical necessity for this appeal. The letter states that her lung disease makes completing "simple tasks very challenging without assistance." The physician recommended additional personal care hours. There was no discussion of currently unmet personal care needs.

The patient's pulmonologist provided a letter of support for this appeal. The letter states that she is being treated for bronchiectasis which causes shortness of breath, making "simple tasks very challenging without assistance." The physician recommended additional personal care hours as medically necessary. There was no discussion of unmet personal care needs.

A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented with minimally impaired cognition; she has been increasingly forgetful but is able to call for help in the event of emergency. From a functional standpoint, she requires total dependence for housework. She requires maximal assistance for meal preparation, shopping, transportation, and stairs. She requires extensive assistance for managing finances and medications. For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, and bed mobility. She had a significant decline in function since her recent admission for respiratory failure. She is frequently incontinent of urine and occasionally incontinent of stool. She uses pull ups to manage incontinence and requires changing about four times per day. An Hours Evaluation for Paraprofessional Support Tool (HELPS) tool associated with the assessment recommended 51 hours per week to meet her personal care needs.

The health plan's determination is upheld.

The requested health service of Consumer Directed Personal Assistance Services to 84 hours a week has not been demonstrated to be medically necessary for this patient.
The patient has had worsening functional status over the past year. She now has difficulty with many Instrumental activities of daily living (IADLs) and ADL's as outlined by her physicians and the UAS. However, the number of hours designated to assist with these tasks is commensurate with her level of functional need. She also has consumer directed hours, and can use them spread out in whatever manner would be more helpful for her. Additionally, there is documentation that family is providing informal support in the evenings. There is no documentation of specific personal care needs that are currently not being met that would warrant an increase in personal care hours beyond what is recommended by the assessment.