Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary Embolism.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) from 35 hours to 56 hours per week.
The insurer denied Consumer Directed Personal Assistance Services (CDPAS) from 35 hours to 56 hours per week.
The determination is overturned.

This is a female patient with a history of a pulmonary embolism, atrial fibrillation, congestive heart failure, hypertension, type 2 diabetes mellitus without complication, glaucoma with bilateral blurry vision, nuclear sclerotic cataract of the left eye, urinary incontinence, vitamin D deficiency, and vitamin B12 deficiency. She lives alone in a 2-bedroom apartment on the sixth floor and the building has a functioning elevator system. She receives support from her son and daughter-in-law. 
The patient's primary care provider (PCP) provided a letter of support recommending an increase in personal care services. This letter states that the patient's mobility, balance, and endurance have deteriorated since she was hospitalized for a pulmonary embolism. Her PCP states that she needs assistance with bathing, dressing, undressing, personal hygiene, stairs, bed transfer, toilet transfer, meal preparation, shopping, housework, transportation, and medication management.
An in-person UAS was performed. Per UAS, the patient's son reported that she lost her balance and fell backward, hitting her back on the floor. She was assessed at maximal assistance for meal preparation, ordinary housework, managing finances, stairs, shopping, and transportation; extensive assistance for managing medications, bathing, dressing lower body; limited assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility; setup help only for phone use; independent for eating. A tasking tool was used to determine that the patient requires 33.92 hours of aide service per week.
Per the preoperative assessment note, she is unable to walk to the bathroom on her own due to worsening vision and has difficulty using her bedside commode. At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS) from 35 hours to 56 hours per week. 

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, 56 hours of CDPAS care is medically necessary.
There is documentation in the UAS of the patient requiring extensive assistance with dressing lower body and toilet use and limited assistance for walking, locomotion, and transfer toilet. The patient's PCP wrote in her letter that the patient's status had deteriorated since her hospitalization and that she requires an increase in personal care services. The UAS performed (which documented that she requires limited assistance with toilet use) is not consistent with her PCP's recommendation and underestimates her needs. The insurer also did not take into account that, per her preoperative medical assessment, she is unable to use the toilet unassisted due to vision loss caused by glaucoma. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. The patient does not have informal support for the entire time outside of the previously assigned CDPAS hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies due to her vision loss. The requested increase in CDPAS hours is not solely for safety and supervision but to assist the patient with activities of daily living (ADLs).