Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Coronary artery disease (CAD), hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), depression, vertigo, anxiety, urinary incontinence, status post atrial valve replacement, history of multiple falls, back pain, knee pain, decreased vision, hearing difficulty
Treatment: Consumer Directed Personal Assistance Services for 84 Hours per Week
The insurer denied: Consumer Directed Personal Assistance Services for 84 Hours per Week
The denial is overturned.

The patient is an adult female with history of general debility. The request was for consumer directed personal assistance services (CDPAS) to be increased from 56 hours per week (8 hours per day, 7 days per week) based on Uniform Assessment System (UAS) of last year to 84 hours per week (12 hours per day, 7 days per week). The health plan denied the request because the patient has a supporting son who can direct her care, that her functional status has remained the same for bathing, personal hygiene, toilet transferring, dressing upper/lower body, toilet use, bed mobility, and walking and that her needs can be scheduled and that she can be left alone safely. Therefore, that the functional status and the estimated time needed to complete the tasks have already been accounted for and are being performed by the aide with the current 56 hours per week. The additional hours requested are because of the patient's chronic medical conditions, and to help with her activities of daily living (ADLs) as she requires extensive assistance with dressing, bathing, grooming, transferring, turning, positioning, toileting, ambulation, meal preparation, eating, housekeeping, and shopping, etc. In addition, the patient has significant cognitive decline, memory loss, substantial fatigue, visual deficit, hearing deficit, frequent falls, ambulation difficulty, etc. A review of the records showed that the patient has multiple chronic medical conditions including coronary artery disease (CAD), hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), depression, vertigo, anxiety, urinary incontinence, status post atrial valve replacement, history of multiple falls, back pain, knee pain, decreased vision, hearing difficulty, difficulty in ambulation, shortness of breath, etc. She lives by herself in a one-bedroom apartment of an elevated apartment building. Uniform Assessment System-New York (UAS-NY) evaluation of 5 months ago showed that the patient required modified independence with making decisions; total dependence for meal preparation, housework, shopping; extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toilet use; maximal assistance with managing finances, managing medications, phone use, bathing, lower body dressing; and limited assistance or independent with toilet transfer, bed mobility, etc.

The requested health service is medically necessary.

The requested increase in consumer directed personal assistance services from 56 hours per week (8 hours per day, 7 days per week) based on Uniform Assessment System of last year to 84 hours per week (12 hours per day, 7 days per week) is medically necessary because based on the most recent Uniform Assessment System of 5 months ago, the patient needs modified independence with making decisions; total dependence for meal preparation, housework, shopping; extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toilet use; maximal assistance with managing finances, managing medications, phone use, bathing, lower body dressing; and limited assistance or independent with toilet transfer, bed mobility, etc. 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 of 5 months ago as stated above. Therefore, the 84 hours per week (12 hours per day, 7 days per week) based on Uniform Assessment System of 5 months ago should be approved. The requested health service is medically necessary.