Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression, gastroesophageal reflux disease (GERD), vitamin deficiency, benign prostatic hypertrophy (BPH), osteoporosis, generalized osteoarthritis, and anxiety
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services for a Total of 56 Hours per Week
The insurer denied: Increase Consumer Directed Personal Assistance Program (CDPAP) Services for a Total of 56 Hours per Week
The denial is overturned.

The patient is an adult male with a history of general debility. The request was for Consumer Directed Personal Assistance Program (CDPAP) to be 56 hours per week (8 hours per day, 7 days per week) as against the previously approved 28 hours per week (4 hours per day, 7 days per week) based on Uniform Assessment System of last year. The patient lives in an 
apartment alone. The health plan denied the request as not medically necessary because the patient's son is supportive of care, the patient is able to walk with light touch/assistance, and 
there were no major changes from previous activities of daily living. The time previously allotted is stated to be adequate.
The additional hours requested are because of the patient's chronic medical conditions and he has a need for someone to help with bathing, meal preparation, housework, shopping, and attending medical appointments along with safety monitoring, etc. A review of the records showed that the patient has multiple chronic medical conditions, including depression, gastroesophageal reflux disease (GERD), vitamin deficiency, benign prostatic hypertrophy (BPH), osteoporosis, generalized osteoarthritis, anxiety, etc. Uniform Assessment System-New York (UAS-NY) evaluation showed that the 
patient is with minimally impaired cognition; requires setup for eating; limited assistance for personal hygiene, bed mobility, walking, locomotion; extensive assistance with upper/lower body dressing, bathing, toilet transfer, toilet use; maximum assistance for meal preparation, managing medications; and totally dependent for housework, etc. This showed that activities of daily living were worse than previously. The patient lives alone with support from his son.

The requested health service is medically necessary.

The requested increase for Consumer Directed Personal Assistance Program (CDPAP) from the previously approved 28 hours per week (4 hours per day, 7 days per week) based on the Uniform Assessment System (UAS) of last year to the requested 56 hours per week (8 hours per day, 7 days per week) is medically necessary based on Uniform Assessment System (UAS) in which the patient requires setup for eating; limited assistance for personal hygiene, bed mobility, walking, locomotion; extensive assistance with upper/lower body dressing, bathing, toilet transfer, toilet use; and maximum assistance for meal preparation, managing medications, and totally dependent for housework, etc. This showed that activities of daily living were worse than previously. The reason for denial by the health plan as stated in the clinical information above does not align with the patient's disability features as stated in the Uniform Assessment System as stated above. Therefore, the 56 hours per week (8 hours per day, 7 days per week) based on Uniform Assessment System of 3 months ago should be approved because the patient is setup for eating; limited assistance for personal hygiene, bed mobility, walking, locomotion; extensive assistance with upper/lower body dressing, bathing, toilet transfer, toilet use; maximum assistance for meal preparation, managing medications, and totally dependent for housework, etc. This showed that activities of daily living were worse than previously.