Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral palsy spastic diplegia. 
Treatment: Increase Consumer and Self Directed Personal Assistance Services (CDPAS) to 84 Hours per Week. 
The insurer denied Increase Consumer and Self Directed Personal Assistance Services (CDPAS) to 84 Hours per Week. 
The denial is overturned. 

The patient is an adult female with a diagnosis of cerebral palsy spastic diplegia. She is currently receiving 35 hours of personal assistant services. The request is for an increase to 84 hours. The patient had an assessment five months ago, which noted that she required maximum assistance with meal preparation, housework, shopping, bathing. She required limited assistance with personal hygiene, extensive assistance with upper and lower body dressing, locomotion, transferring, toileting, limited assistance with bed mobility. She was independent with eating. Total hours resulted in 34 hours per week. It is noted that the patient requires an aide, caregiver, or family member to be on site with her throughout the day and night to ensure that she is able to safely remain in home. 

The Increased Consumer and Self Directed Personal Assistance Services (CDPAS) to 84 Hours per Week is medically necessary. 

A final adverse determination was reviewed where the plan had approved 35 hours per week. A request was made for an increase to 84 hours. The patient did have an assessment five months ago where it demonstrated that the patient needed assistance with meal preparation, housekeeping, shopping, laundry, bathing, dressing, toileting. The patient did have a utilization of a motorized wheelchair and cane for ambulation. It should also be noted that the patient has family members that can also provide the necessary services. A letter from the provider outlined the patient's past medical history noting that she requires assistance in mobility and all ADLs (activities of daily living). It is noted in the documentation from the provider, the patient requires an aide, caregiver, or family member to be on site with her throughout the day and night. Initial information was reviewed which noted that the patient had multiple falls while attempting to get up from her bed. It seems the majority of the falls occurred while attempting to get out of bed or the tub. It also demonstrated that the daughter is not always available to provide adequate supervision for the prevention of falls. The previous request was for 84 hours for 7 days (12 hours/day). After further review, although the patient does live with a family member, that particular family member is not always available to address the persistent falls that this patient experiences, the majority of which seem to be stemming from attempts to get out of bed. The previous documentation also took that into account and noted that the services do not provide safety supervision or when there is no task being done. It was noted that increasing the hours of the aide would not prevent further falls or injuries. The complaint letter noted that her family is limited in providing her care. It was noted that the patient's family member could provide a maximum of 4 hours of support in a 3 day period. Furthermore, the letter noted that the patient could possibly be unable to change her own incontinence products. With the inconsistent family support for this patient who, although medically stable, one can expect a regression of her disease resulting in progressive inability to manage activities of daily living and failure to thrive. It seems that the consensus is that the initial 35 hours would not be helpful for this patient. The increase hours to 84 would be considered medically necessary given that the patient does not have sufficient family support and would be at risk for falls and incontinence during the time that the personal care assistance is not there.