Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Status post back surgery.
Treatment:  Increase Consumer Directed Personal Assistance Service (CDPAS) To 7 Days Per Week, 8 Hours Per Day A Total 56 Hours Per Week.

The insurer denied Increase Consumer Directed Personal Assistance Service (CDPAS) To 7 Days Per Week, 8 Hours Per Day A Total 56 Hours Per Week.  The denial is overturned.

The patient is an adult female. She has a history of general debility due to chronic low back due to lumbar spinal stenosis. This is associated with neurogenic claudication. She is status post two spinal surgeries last month. These are associated with complication, with an ensuing significant decline in her functional status. The request was for Consumer Directed Personal Assistance Service (CDPAS) to be increased from 31.5 hours per week (4.5 hours per day, 7 days per week), which was initially based on UAS (Uniform Assessment System) Evaluation of 7 months ago. The requested increase is to 56 hours per week (8 hours per day, 7 days per week), based on the UAS (Uniform Assessment System) evaluation of last month. The health plan denied coverage of the request, citing that the patient can feed herself with meals prepared in advance by her PCA (personal care aide), and she is able to direct her care and activates the personal emergency response system. Also, her ADLs (activities of daily living), such as grooming, dressing, bathing, transferring, walking, toileting, meal preparation, and feeding are sufficiently infrequent and can be safely and adequately met through the approved weekly hours. The additional hours requested are because of the patient's chronic medical conditions, chronic low back due to lumbar spinal stenosis associated with neurogenic claudication, and because she is status post two spinal surgeries, which are associated with complications and ensuing significant decline in her functional status. She is at increased risk of falls due to unsteady gait. To help with her Activities of Daily Living (ADLs), she requires extensive assistance with dressing, bathing, grooming, transferring, turning, positioning, toileting, ambulation, meal preparation, eating, housekeeping, shopping, and appointments to see her physicians. A review of the records showed that the patient has multiple chronic medical conditions, including lumbar stenosis status post two surgeries, anxiety, bipolar disorder, depression, diabetes mellitus, repeated falls, and restless leg syndrome. UAS (Uniform Assessment System) evaluation of last month showed that the patient is cognitively intact and independent, and she makes decisions reasonably and safely. She required limited assistance with managing finances, phone use, walking, locomotion, bed mobility, extensive assistance with managing medications, personal hygiene, upper body dressing, toilet use/transfer, eating, maximal assistance for meal preparation, housework, shopping, 
transportation, bathing, and lower body dressing. She was noticed to walk with the aid of a walker with an unsteady gait.
The patient lives in a three-bedroom mobile home with three steps to enter. She lives with her partner, daughter, daughter's spouse, and her two grandsons.

The requested Increase Consumer Directed Personal Assistance Service (CDPAS) To 7 Days Per Week, 8 Hours Per Day A Total 56 Hours Per Week is medically necessary.

The patient is cognitively intact and independent. She makes decisions reasonably and safely. She requires limited assistance with managing finances, phone use, walking, locomotion, bed mobility, extensive assistance with managing medications, personal hygiene, upper body dressing, toilet use/transfer, eating, maximal assistance for meal preparation, housework, shopping, transportation, bathing, and lower body dressing. It was noted during her UAS (Uniform Assessment System) evaluation that she walks with the aid of a walker with an unsteady gait. The reasons for denial by the health plan as stated in the clinical information above, do not align with her disability features as noted in the UAS (Uniform Assessment System) evaluation of last month. Therefore, given the above, the requested increase to 56 hours per week (8 hours per day, 7 days per week) is medically necessary.