Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness
Treatment: Consumer Directed Personal Assistance Services (CDPAS) from 28 hours (hrs) to 49 hrs per week
The insurer denied Consumer Directed Personal Assistance Services (CDPAS) from 28 hours (hrs) to 49 hrs per week.
The determination is overturned.

This is a female patient with a medical history notable for dizziness. The patient is approved for 28 hours per week of consumer directed personal assistance services. The patient and her care team requested and increased to 49 hours per week, and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has a medical history notable for dizziness, imbalance, unsteadiness on her feet, polyarthritis, cervical radiculopathy, back pain, history of lung cancer, history of lumpectomy status post chemotherapy and radiation, hypertension, coronary artery disease, acid reflux, cognitive deficit, and insomnia. The patient ambulates with a cane and assistance from her home health aide and is at high risk for falls. She has been physically and cognitively declining and the physician reports that she cannot be left alone during the day as she is dependent on her caretaker for all daytime activities. She requires assistance with ambulation, bathing, meal preparation, medication prompting, and transportation. The physician recommends the requested increase as medically necessary for the patient.
A Uniform Assessment System (UAS) was completed. The patient was alert and oriented but frequently forgetful. She is able to direct her own care. Recall was zero out of three after 5 minutes. For her instrumental activities of daily living, the patient requires total dependence for housework. She requires maximal assistance for meal preparation and shopping. She requires extensive assistance for all others. For her activities of daily living, the patient requires extensive assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, and bed mobility. She ambulates with a cane and requires extensive assistance with activities of daily living as noted above. She is occasionally incontinent of urine and is continent of stool. A task tool associated with the assessment recommended 26.25 hours per week to address her personal care needs, a decrease from the 28 hours recommended on a prior assessment. Compared to a prior assessment , the patient showed a decline in level of function on activities of daily living. At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS) from 28 hours (hrs) to 49 hrs per week.

The requested health service of increase in Consumer Directed Personal Assistance Services (CDPAS) from 28 hrs to 49 hrs per week is medically necessary for this patient.
The patient has mobility limitations as outlined in the assessment and the letter from the physician. She requires assistance with most activities of daily living including transfers and toileting. Her condition has declined as indicated by the assessment, although the level of recommended hours actually decreased from a prior recommendation. Given that her condition is progressively worsening, a modest increase in personal hours is medically necessary and reasonable. The physician attested to the patient's worsening condition and need for additional care hours to assist with her daytime health needs. Her care needs can be expected to be somewhat unscheduled throughout the day, as toileting needs cannot be predicted. Therefore, the requested increase is medically necessary and reasonable for the patient.