Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) stroke with residual right-sided hemiparesis
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 24 Hours a Day, 7 Days a Week (Live-In) for a Total of 91 Hours
The insurer denied the Consumer Directed Personal Assistance Services (CDPAS) 24 Hours a Day, 7 Days a Week (Live-In) for a Total of 91 Hours
The denial is overturned

The patient is a male. His medical conditions include a stroke with residual right-sided hemiparesis. Denial of Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week (live-in) for a total of 91 hours is being appealed. He has been approved for CDPAS (Consumer Directed Personal Assistance Services) 56 hours per week. Additional hours were requested due to muscle weakness and need for nighttime assistance. He lives with his friend.

UAS (Uniform Assessment System) evaluation completed shows the patient has minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, personal hygiene, dressing, walking, locomotion, and toileting; and extensive assistance with managing finances and medications, phone use, bed mobility and eating. He uses a wheelchair at home. He has infrequent urinary incontinence.

There is a daily schedule from a home health aide that notes the patient needs assistance to go to the bathroom several nights during the week. An incident log shows multiple falls.

Clinical notes are provided documenting the patient has mobility limitations and needs help 24 hours with ADLs (activities of daily living).

An appeal statement notes the patient has a history of falls due to unsteady gait and needs assistance with ADLs (activities of daily living). States the patient is unable to complete ADLs (activities of daily living) due to right-sided paresis. Notes he needs assistance with toileting needs multiple times through the night. The friend he lives with is unable to provide informal support.

Yes, the Consumer Directed Personal Assistance Services (CDPAS) 24 Hours a Day, 7 Days a Week (Live-In) for a Total of 91 Hours 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. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week (live-in) for a total of 91 hours is being appealed. He has been approved for CDPAS (Consumer Directed Personal Assistance Services) 56 hours per week. The Plan denied additional hours, noting aides do not manage medical conditions and overnight services for safety supervision is not covered.

This patient has medical conditions including being wheelchair bound due to a stroke with residual right-sided hemiparesis. UAS (Uniform Assessment System) evaluation completed shows the patient requires extensive to maximal assistance with all ADLs (activities of daily living) and total dependence with housework. He has urinary incontinence. Appeal documents show the patient needs assistance with transfers and has multiple falls due to impaired gait. There is an incident log provided showing multiple falls. There is a daily schedule report noting the need for nighttime assistance with toileting. This patient requires significant assistance with ADLs (activities of daily living) and personal care. He does not have informal support. Live-in personal care is appropriate or needs that include transferring and toileting. The approved CDPAS (Consumer Directed Personal Assistance Services) 56 hours per week is insufficient to meet this patient's needs for assistance with for ADLs (activities of daily living) and personal care. The proposed CDPAS (Consumer Directed Personal Assistance Services) 24 hours a day, 7 days a week (live-in) for a total of 91 hours is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.