Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke with left hemiparesis. 
Treatment: Consumer Directed Personal Assistance Services 8 hours per day, 7 days per week, for a total of 56 hours per week. 
The insurer denied coverage for Consumer Directed Personal Assistance Services 8 hours per day, 7 days per week, for a total of 56 hours per week. 
The denial is overturned. 

This male has a history of a stroke with left hemiparesis and needs assistance with most daily activities. He lives with his daughter and grandchildren. He has been receiving personal care services as Consumer Directed Personal Assistance Services (CDPAS) 3 or 4 hours per day, 7 days per week, for a total of 24 hours per week. The patient requested an increase of CDPAS hours, but the final adverse determination (FAD) letter indicated that the request for additional services did not include a specific number of hours. The task-based tool completed with the UAS (uniform assessment system) included a comment regarding patient request for additional aide hours; noted as 7 days x 8 hours. The request for additional CDPAS hours was denied; with approval for continuation of CDPAS 24 hours per week. External appeal was requested. 

The most recent UAS provided was reviewed. The patient's functional status report for IADLs (instrumental activities of daily living) indicates the patient needs maximal assistance for meal preparation, housework, and shopping; extensive assistance for transportation, stairs: limited assistance for managing finances and medications; and set up help for phone use. For ADLs (activities of daily living), the patient needs extensive assistance for bathing, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use; limited assistance for personal hygiene; supervision for eating, bed mobility. 

The UAS indicates the patient needs extensive assistance with mobility, including walking and transfers (the UAS reports patient has difficulty moving to standing position unassisted). Mobility also includes toileting which involves walking to the bathroom and transfer on/off the toilet. The UAS reports patient has an unsteady gait. This is probably primarily due to the stroke, but the UAS also reports the patient has foot problems that limit walking (no details are noted). Two falls were reported in the UAS (both were a few days prior to the UAS). It was noted that the patient attempts to transfer from bed unassisted, and it reasonable to consider that he may transfer from a chair unassisted as well, especially if he is alone. Following a stroke, there is often an adjustment period when the affected person needs to recognize, remember, and accept new limitations to routine function. The patient's prior level of function (before the stroke) is not noted; but the records suggest that the patient was most likely independent with daily activities prior to his stroke (there is no medical history to suggest any other significant functional limitations prior to the stroke). 

Considering the patient's medical history and functional impairment, it is medically necessary for the patient to have assistance with daily activities when needed throughout the day. This includes meals (the aide needs to assist with meal preparation/service, and possibly with eating for breakfast and lunch; and possibly dinner if family arrives home late); routine morning ADLs (i.e., bathing, dressing, personal hygiene, toileting); and mobility and toileting tasks that occur at various, unscheduled and recurring times of the day. 

Recommendation is given to approve Consumer Directed Personal Assistance Services 8 hours per day, 7 days per week, total of 56 hours per week. 

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 an increase in Consumer Directed Personal Assistance Services (CDPAS) hours is overturned. Medical Necessity is substantiated.