Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Consumer directed personal assistance 70 Hours/ Week (health plan approved 42 hours/week).
The insurer denied the Consumer directed personal assistance 70 Hours/ Week (health plan approved 42 hours/week).
The denial is overturned.

This female has multiple conditions including dementia, depression, and osteoarthritis with impairing dexterity.  She is appealing denial of consumer directed personal assistance 70 hours per week.  The plan approved 42 hours per week.  She lives with her daughter.  

UAS evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, and transportation; extensive assistance with phone use, stairs, bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility; and independent with eating.  She ambulates with a walker with assistance.  She has frequent bladder and bowel incontinence.  Compared to UAS evaluation completed previously, there has been a decline in ability to perform meal preparation, housework, managing finances, shopping, personal hygiene, walking, locomotion, toileting and bed mobility.  Bowel incontinence has increased.  

An appeal statement from the member's child notes she forgets and forgets medications for asthma.  States someone needs to be with her all the time, especially is she wants to go outside. 

An appeal statement from the provider notes the member needs assistance with ADLs as already accounted for in the UAS evaluation.  Notes the member is confused and disoriented.  States she requires verbal cues, prompting and supervision with tasks.  

An appeal letter from two additional providers notes the member has progressive dementia and needs assistance with ADLs as already accounted for in the UAS evaluation. Notes she she has poorly controlled diabetes, hypertension and asthma.

Yes. The proposed treatment 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 member has multiple chronic conditions, including progressive dementia.  She is appealing denial of consumer directed personal assistance 70 hours per week.  The plan approved 42 hours per week. UAS (uniform assessment system) evaluation completed shows the member requires assistance with all ADLs (activities of daily living) except eating.  She has frequent bladder and bowel incontinence.  Compared to UAS (uniform assessment system) evaluation completed previously, there has been a decline in ability to perform meal preparation, housework, managing finances, shopping, personal hygiene, walking, locomotion, toileting and bed mobility.  Appeal letters note the member has progressive dementia and needs assistance with ADLs (activities of daily living) as well as supervision. PCS (personal care support) is not indicated for supervision and management of medical conditions. However, the UAS (uniform assessment system) evaluations show deterioration in physical functioning. The member requires significant assistance with ADLs (activities of daily living) and personal care. The approved CDPAS (Consumer Directed Personal Assistance) 42 hours per week is insufficient to meet the member's needs for assistance with ADLs/IADLs. The proposed increase in CDPAS (Consumer Directed Personal Assistance) to 70 hours per week is medically necessary.

No. The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.