Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, hypertension, hyperlipidemia, and gastroesophageal reflux disease
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP)15.5 Hours per Week and Personal Care Aide 16 Hours per Week for a Total Amount of 56 Hours per Week
The insurer denied: Increase Consumer Directed Personal Assistance Program (CDPAP) 15.5 Hours per Week and Personal Care Aide 16 Hours per Week for a Total Amount of 56 Hours per Week
The denial is overturned.

This elderly female patient has medical conditions that include osteoarthritis, hypertension, hyperlipidemia, and gastroesophageal reflux disease. She was hospitalized recently with urinary tract infection and bowel obstruction. She lives
with her daughter. The denial of 40 hours per week Consumer Directed Personal Assistance Program (CDPAP) and 16 hours per week Personal Care Aide (PCA) services for a total of 56 hours is being appealed. The health plan approved Consumer Directed Personal Assistance Program 24.5 hours per week.

Uniform Assessment System evaluation completed 4 months ago shows minimallyimpaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, manning medications, shopping; extensive assistance with managing finances, bathing, lower body dressing,
walking, locomotion, toileting, and bed mobility; limited assistance with personal hygiene and upper body dressing; and independent with eating. She has occasional bladder incontinence. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with dressing, personal hygiene,
toileting, bathing, walking, locomotion, and bed mobility. A letter from the patient's daughter notes the patient's ability has worsened and she needs assistance with activities of daily living. She gets up multiple times per night to go to the bathroom.
She has a history falls. She wants a companion. The daughter is the personal assistance and son-in-law are supportive. The patient's family is requesting additional hours due to physical decline. The patient has knee arthritis and needs
assistance with ambulation and activities of daily living. A letter notes the patient's functional status has declined since recent hospitalizations. The patient now requires a higher level of assistance with activities of daily living. Medical records show need for durable medical equipment and assistance with activities of daily living. Medical records do not show skilled nursing needs.

Yes, the requested health service is medically necessary.
This patient is requesting a total of 56 hours of personal care services.  The patient had requested a split between CDPAP (Consumer Directed Personal Assistance Program) and PCS (Personal Assistance Services).  The reconsideration request supports that the patient does not have skilled nursing needs, but does not clarify the patient's request to split services. The UAS (Uniform Assessment System) evaluations and appeal statements support that there has been a decline in the patient's functioning and the need for an increase in personal care services.  The proposed increase personal care services to a total of 56 hours are medically indicated.