Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Monocular vision, glaucoma, neuropathy.
Treatment:  Increase Consumer Directed Personal Assistant (CDPAP) Total 40 Hours Per Week.

The insurer denied Increase Consumer Directed Personal Assistant (CDPAP) Total 40 Hours Per Week.  The denial is overturned.

This elderly male patient has medical conditions including monocular vision, glaucoma, dysthymia, hypertension, hyperlipidemia, arthralgia, hearing loss, neuropathy, and insomnia. He is appealing the denial of an increase in consumer directed personal assistance program (CDPAP) to total 40 hours per week. The health plan approved 30 hours per week. 

Uniform Assessment System (UAS) evaluation completed recently shows minimally impaired cognition and functional status: total dependence with managing finances, and shopping; maximal assistance with meal preparation, housework, managing medication, phone use, and bathing; extensive assistance with personal hygiene, dressing, walking, locomotion, toileting, and bed mobility; and independent with eating. The patient has occasional urinary incontinence. Compared to Uniform Assessment System (UAS) evolution completed last year, there has been a decline with managing finances and medications, phone use, and bed mobility. There has been an improvement with meal preparation, housework, and personal hygiene. The patient's son and daughter-in-law provide informal support. A letter from the Provider notes the patient has right-sided vision loss and bilateral corneal ulcers that require antibiotic drops. A letter from another Provider notes the patient is high risk for fall due to age and vision impairment. The patient has limited range of motion and needs assistance administering medications as well as with activities of daily living (ADLs).

The proposed treatment is medically necessary.

Personal Care Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs), health maintenance activities, and routine support services. This patient has multiple chronic medical conditions. He is appealing the denial of an increase in consumer directed personal assistance program (CDPAP) to total 40 hours per week. The health plan approved 30 hours per week. The health plan denied an increase in hours based on the Uniform Assessment System (UAS) evaluation and informal support received. Uniform Assessment System (UAS) evaluation completed recently shows the patient needs assistance with all activities of daily (ADLs), except eating. Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with managing finances and medications, phone use, and bed mobility; and there has been an improvement with meal preparation, housework, and personal hygiene. The patient's son and daughter-in-law provide informal support. Appeal statements note the patient needs assistance with medications due to partial vision loss and is a fall risk. This patient's physical functioning is significantly impaired and remains so despite some improvement between Uniform Assessment System (UAS) evaluations. This need for extensive assistance to total dependence with activities of daily living (ADLs) cannot be met with the approved consumer directed personal assistant program (CDPAP) total 30 hours per week. The proposed increase in consumer directed personal assistance program (CDPAP) to total 40 hours per week per week is medically necessary and appropriate.