Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer on chemotherapy, heart disease, diabetes, obesity, osteoporosis, diabetic neuropathy, and osteoarthritis. 
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) To 7 Days Per Week, 8 Hours Per Day; A Total of 56 Hours Per Week. 

The insurer denied: Increase Consumer Directed Personal Assistance Services (CDPAS) To 7 Days Per Week, 8 Hours Per Day; A Total of 56 Hours Per Week. 

The denial is overturned. 

The patient is an elderly female. Her medical conditions include breast cancer on chemotherapy, heart disease, diabetes, obesity, osteoporosis, diabetic neuropathy, and osteoarthritis. She lives alone. Denial of increase consumer directed personal assistance services (CDPAS) to seven days per week, eight hours per day, a total of 56 hours per week, is being appealed. The health plan approved 4.5 hours per day, a total of 31.5 hours per week. 

Uniform Assessment System (UAS) evaluation completed 5 months ago shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with bathing and dressing; limited assistance with managing finances and medications, personal hygiene, walking, locomotion, eating, and toileting; and independent with bed mobility. She has bowel and bladder incontinence. Uniform Assessment System evaluation completed 3 months ago shows a decline with meal preparation, housework, and managing finances. A letter from the patient's provider notes the patient has a rapidly deteriorating mental and physical status. She has impaired coordination, limited range of motion, and reduced mobility, and she requires a walker for ambulation. She wears diapers and requires multiple diaper changes. She requires continuous supervision and assistance with activities of daily living (ADLs). An appeal letter from the patient's designee notes that the patient is weak. The patient cannot get out of bed by herself. She is incontinent and cannot change pull-ups herself. She needs assistance with activities of 
daily living. 

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. Denial of increase consumer directed personal assistance services (CDPAS) to seven days per week, eight hours per day, a total of 56 hours per week, is being appealed. The health plan approved 4.5 hours per day, a total of 31.5 hours per week. This patient has multiple chronic conditions. She lives alone. Uniform Assessment System evaluation 4 months ago shows she requires assistance with all activities of daily living (ADLs), except bed mobility. Uniform Assessment System evaluation completed 3 months ago shows a decline with meal preparation, housework, and managing finances. Appeal statements note the patient's mental and physical condition is deteriorating. The patient has incontinence and requires assistance with toileting and diaper changes multiple times per day. The information provided supports a significant decline in the patient's level of function with some decline over a few months. She has significant limitations that cannot be managed with the approved CDPAS (consumer directed personal assistance services) of 31.5 hours per week. The requested increase to 56 hours per week is medically necessary.