Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
Treatment: Increase in Consumer-Directed Personal Assistance Program (CDPAP) Services, Eight (8) Hours Per Day, Five (5) Days Per Week (Total Amount of 40 Hours Per Week)
The insurer denied the Increase in Consumer-Directed Personal Assistance Program (CDPAP) Services, Eight (8) Hours Per Day, Five (5) Days Per Week (Total Amount of 40 Hours Per Week)
The denial is overturned.

This female has diagnoses including Alzheimer's dementia.  She has muscle weakness, unsteady gait, and vision trouble.  This is appeal for denial of consumer-directed personal assistance program (CDPAS) services 40 hours per week.  She has been approved for consumer-directed personal assistance program (CDPAS) services 25 hours per week.  The patient does not have informal support.  Uniform Assessment System (UAS) evaluation performed shows moderately impaired cognition and functional status as follows: total dependence with housework and shopping; maximal dependence with meal preparation, managing finances and medications; extensive assistance with phone use, bathing, walking, locomotion, and toileting; limited assistance with lower body dressing; supervision with personal hygiene, upper body dressing and eating; and independent with bed mobility. She has bowel and bladder incontinence.  Compared to a Uniform Assessment System (UAS) evaluation performed previously, there is a decline in cognition and dependence for shopping, bathing, personal hygiene, dressing, and toilet transfer.   

An appeal letter from a family member states that the patient is declining and needs dressing and toileting addressed more frequently.  A letter from the physician states that the patient's dementia is progressing and she needs assistance with activities of daily living (ADLs), including eating.

Yes, the proposed increase in consumer-directed personal assistance program (CDPAP) services, eight (8) hours per day, five (5) days per week (40 hours total per week) is 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 conditions including dementia.  She has muscle weakness, unsteady gait, and vision trouble.  The requested consumer-directed personal assistance program (CDPAS) services 40 hours per week was denied.  She has been approved consumer-directed personal assistance program (CDPAS) services 25 hours per week.  

Uniform Assessment System (UAS) evaluation completed shows that the patient requires assistance with housework, shopping, meal preparation, managing finances and medications, phone use, bathing, walking, locomotion, toileting and with lower body dressing.  Compared to the Uniform Assessment System (UAS) evaluation performed previously, there is a decline in cognition and dependence for shopping, bathing, personal hygiene, dressing, and toilet transfer.  The appeal letters indicate that the patient's cognition and physical functioning have declined. This is supported by the Uniform Assessment System (UAS) evaluations.  She is incontinent of bladder and has demonstrated the need for assistance with transfers.  Based on this patient's needs for assistance with activities of daily living (ADLs)/instrumental activities of daily living (IADLs) and decline in cognition and functioning, the currently approved consumer-directed personal assistance program (CDPAS) services 25 hours per week is insufficient to meet this patient's needs.  The proposed consumer-directed personal assistance program (CDPAS) services 40 hours per week is medically necessary.