Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, dementia
Treatment: Consumer Directed Personal Assistance Services (CDPAS); 64 hours per week, 9-10 hours per day, 7 days per week
The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS); 64 hours per week, 9-10 hours per day, 7 days per week
 The denial is overturned

This patient has experienced functional decline and needs assistance for all daily activities. The patient lives with her daughter. The daughter works from home and has been having difficulty managing her work and providing care for her mother during work hours. The patient had been receiving personal care services as Consumer Directed Personal Assistance Services (CDPAS) 14 hours per week. The daughter (as patient designee) requested an increase of CDPAS to 64 hours per week, which was denied; but CDPAS was increased to 35 hours per week. The daughter appealed the decision. Denial for CDPAS 64 hours per week was upheld, but services were increased to 42 hours per week; and it was noted in the final denial letter that services were changed to personal care aide (PCA) services. An external appeal was requested.

The most recent UAS (uniform assessment system) provided for review was done. The functional status report for IADLs (instrumental activities of daily living) indicated the patient was totally dependent for ordinary housework and managing finances; she needs maximal assistance for meal preparation, managing medications, shopping, transportation; extensive assistance for stairs, and phone use. For ADLs (activities of daily living), the patient needs maximal assistance for dressing her lower body; extensive assistance for bathing, personal hygiene, dressing upper body, transfer toilet, toilet use; limited assistance for walking, locomotion, bed mobility; and setup help for eating.

As per the daughter's history, the patient had a shunt placed for hydrocephalus years ago. Hydrocephalus in older people often causes dementia, urinary incontinence and/or urgency, and gait abnormality/poor balance.  Shunting can result in varying degrees of improvement of symptoms. There are no medical records available describing the patient's clinical course from initial symptoms to the present time; and so, it is not clear to what extent (if any) the patient's current cognitive impairment, urinary frequency/incontinence and gait abnormality can be attributed to hydrocephalus. 

The patient may have other neurologic cause(s) of some of her symptoms. The patient has a h/o (history of) stroke. In addition to cognitive impairment/dementia (as previously noted), stroke may result in loss of motor function that may have affected the patient's gait. The UAS reports the patient's food needs to be soft or cut into small pieces. The reason is not noted, but the patient may have some degree of dysphagia. 

As per the request for services in the insurer's final adverse determination letter, recommendation is given to approve Consumer Directed Personal Assistance Services, 64 hours per week, 9-10 hours per day, 7 days per week.

NOTE: This recommendation for personal care services 64 hours per week can be used as Consumer Directed Personal Assistance Services, or Personal Care Aide services, or combination of both.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the Consumer Directed Personal Assistance Services (CDPAS); 64 hours per week, 9-10 hours per day, 7 days per week is overturned. Medical Necessity is substantiated.