Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glaucoma, hard of hearing, lymphedema,hypertension, lumbar disc disorder, and peripheral neuropathy.
Treatment: Consumer Directed Personal Assistance Service (CDPAS) 56 Hours Per Week, Eight Hours Per Day, Seven Days Per Week.
The insurer denied the Consumer Directed Personal Assistance Service (CDPAS) 56 Hours Per Week, Eight Hours Per Day, Seven Days Per Week.
The denial is upheld.

This male has medical conditions including decreased vision due to glaucoma, hard of hearing, lymphedema, hypertension, lumbar disc disorder, and peripheral neuropathy.  The patient's spouse died a few months prior.  He lives alone.  He is appealing denial of Consumer Directed Personal Assistance Service (CDPAS) 56 hours per week, eight hours per day, seven days per week.  He has been approved for Consumer Directed Personal Assistance Service (CDPAS) 35 hours per week; five hours per day, seven days per week.  

Uniform Assessment System (UAS) evaluation completed shows minimally impaired cognition and functional status: total dependence with meal preparation, and housework; maximal assistance with managing medications and finances, and shopping; extensive assistance with phone use, stairs, bathing, lower body dressing, and toilet use; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toilet transfer; supervision with eating; and Independent with bed mobility.  He has occasional bladder incontinence.  Durable medical equipment (DME) includes walker, cane, shower chair, grab bars, flexitouch, urinal and commode.  He had a fall in the last 90 days after missing the chair.  There is no change in health care need computed to Uniform Assessment System (UAS) evaluation completed previously.  His family provides informal support.

An appeal statements note that patient needs assistance with activities of daily living (ADLs) more than five hours per day to participate in doctor's appointments and activities of daily living (ADLs).

No, the proposed treatment is not medically necessary.
Personal Assistance 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 denial of Consumer Directed Personal Assistance Service (CDPAS) 56 hours per week, eight hours per day, seven days per week.  He has been approved for Consumer Directed Personal Assistance Service (CDPAS) 35 hours per week; five hours per day, seven days per week.  Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with meal preparation, housework, managing medications and finances, shopping, phone use, stairs, bathing, lower body dressing, toilet use, personal hygiene, upper body dressing, walking, locomotion, and toilet transfer  this includes limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toilet transfer.  He has occasional bladder incontinence.  There is no change in health care need computed to Uniform Assess System (UAS) evaluation completed previously.  The appeal statement requests additional hours for assistance with activities of daily living (ADLs) and doctors' appointments.  The patient has family that can provide informal support.  Personal Care services are not indicated for supervision or when no tasks are being performed.  The approved personal care services (PCS) 35 hours per week is appropriate and sufficient to meets the patient's needs for assistance with activities of daily living (ADLs) and personal care.  The proposed increase in personal care services to total 56 per week is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.