Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis.
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services for a Total Amount of 70 Hours Per Week.
The insurer denied: Increase Consumer Directed Personal Assistance Program (CDPAP) Services for a Total Amount of 70 Hours Per Week.
The denial is overturned.

The patient is an adult female. The request is for an increase in consumer directed personal assistance program (CDPAP) services for a total amount of 70 hours per week. The health plan approved 28 hours per week. The plan denied the requested hours based on Uniform Assessment System evaluation completed seven months ago. The evaluation showed the patient required set up for personal hygiene and eating, limited assistance with upper body dressing, bed mobility, and 
medication management; extensive assistance with walking, locomotion, toileting; and maximal assistance with lower body dressing, bathing, and meal preparation; and total dependence with housework.
A statement from the patient's provider notes the patient has amyotrophic lateral sclerosis, restless legs syndrome, and peripheral neuropathy. The patient needs total assistance with ADLs (activities of daily living). She lives with her family, but they are unable to provide informal assistance. An increase in hours is requested to meet the patient's needs with personal care.
A letter from the patient's daughter notes that she is the caregiver. The patient's health has declined since the diagnosis. The patient requires total assistance with ADLs (activities of daily living).

The requested Increase Consumer Directed Personal Assistance Program (CDPAP) Services for a Total Amount of 70 Hours Per Week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has amyotrophic lateral sclerosis. Denial of an increase in consumer directed personal assistance program (CDPAP) services for a total amount of 70 hours per week is being appealed. 
The health plan approved 28 hours per week. The health plan denied the increase based on the UAS (Uniform Assessment System) evaluation completed seven months ago. The evaluation showed the patient required set up for personal hygiene and eating, limited assistance with upper body dressing, 
bed mobility, and medication management; extensive assistance with walking, locomotion, toileting; and maximal assistance with lower body dressing, bathing, and meal preparation; and total 
dependence with housework. Appeal statements note that the patient's condition is deteriorating, and she requires total assistance. This patient has a progressive condition with significant impairments in her functioning. The approved CDPAP (consumer directed personal assistance program) 28 hours per week is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living) as noted above. The requested increase in CDPAP (consumer directed personal assistance program) to 70 hours per week is medically necessary.