Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eagle Barrett Syndrome.
Treatment: Consumer Directed Personal Assistance - 70 Hours per Week.

The insurer denied Consumer Directed Personal Assistance - 70 Hours per Week. The health plan's determination is upheld.

This patient is an infant male patient with a history of Eagle Barrett syndrome variant with imperforate anus now with descending colostomy and mucus fistula formation, left club foot, dysplastic sacrum, anomalous lumbar (L) 1 and L2 vertebrae, and vesicostomy. The patient lives with his mother and three older siblings. 

The patient was previously approved for Consumer Directed Personal Assistance Services (CDPAS) for 7 hours per week. The patient's care team requested 70 hours per week of CDPAS. 

The Consumer Directed Personal Assistance Services (CDPAS) for 70 hours per week are not medically necessary. 

Parents are responsible for all housekeeping tasks and activities of daily living for infants, including dressing, bathing, and toileting. CDPAS is not intended to provide childcare or replace the basic responsibilities of a parent. The patient's primary care provider (PCP) states that the patient requires continuous care throughout the day to change colostomy and vesicostomy bags. However, the time required to change colostomy and vesicostomy bags would be similar to or minimally increased above the time usually needed to change infant diapers. The recent Uniform Assessment System (UAS) states that the infant's condition affects the performance of bathing, dressing, and toilet use tasks. The minimal increase in time required to perform these activities of daily living (ADL) beyond what is expected for a healthy infant is accounted for in the CDPAS hours provided by the Plan. The patient does not have any other medical or ADL needs. CDPAS hours are not provided for safety and supervision only.

The patient was previously approved for Consumer Directed Personal Assistance Services (CDPAS) for 7 hours per week. The patient's care team requested 70 hours per week of CDPAS. 

The Consumer Directed Personal Assistance Services (CDPAS) for 70 hours per week are not medically necessary.
Parents are responsible for all housekeeping tasks and activities of daily living for infants, including dressing, bathing, and toileting. CDPAS is not intended to provide childcare or replace the basic responsibilities of a parent. The patient's PCP (primary care provider) states that the patient requires continuous care throughout the day to change colostomy and vesicostomy bags. However, the time required to change colostomy and vesicostomy bags would be similar to or only minimally increased above the time normally required to change infant diapers. The recent Uniform Assessment System (UAS) states that the infant's condition affects the performance of the tasks of bathing, dressing, and toilet use. The minimal increase in time required to perform these activities of daily living (ADL) beyond what is expected for a healthy infant is accounted for in the CDPAS hours provided by the Plan. The patient does not have any other medical or ADL needs. CDPAS hours are not provided for safety and supervision only.