Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neuropathy, COPD (chronic obstructive pulmonary disease), cognitive impairment, and osteoarthritis.
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services For A Total of 91 Hours Per Week
The insurer denied: Increase Consumer Directed Personal Assistance Program (CDPAP) Services For A Total of 91 Hours Per Week
The denial is overturned.

The patient is an elderly female. Her conditions include neuropathy, COPD (chronic obstructive pulmonary disease), cognitive impairment, and osteoarthritis. She lives with her son-in-law, daughter, and granddaughter. Denial of increase consumer directed personal assistance program (CDPAP) services for a total of 91 hours per week is being appealed. The plan approved 8.5 hours per day, 7 days per week, for a total of 59.5 hours per week.

Uniform Assessment System (UAS) evaluation shows minimally impaired cognition and functional status: total dependence with housework, stairs shopping, transportation, lower body dressing, locomotion, and toilet use; maximal assistance with meal preparation, managing finances and medications, bathing, personal hygiene, upper body dressing, walking, toilet transfer, phone use, and bed mobility; and supervision with eating. The patient has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with locomotion, and phone use.

An appeal statement notes that the plan has minimized the patient's functional impairment, and the patient's daughter is providing limited informal support. A letter from the patient's son-in-law notes the patient needs 24 hour homecare due to functional impairments. The patient relies fully on others to perform ADLs (activities of daily living). Her ADL (activity of daily living) status has declined. A letter from the patient's provider notes the patient is home bound. She needs overnight care and help with toileting overnight. She needs to be turned and needs assistance with ADLs (activities of daily living).

The requested Increase Consumer Directed Personal Assistance Program (CDPAP) Services For A Total of 91 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. Denial of increase consumer directed personal assistance program (CDPAP) services for a total of 91 hours per week is being appealed. The plan approved 8.5 hours per day, 7 days per week, for a total of 59.5 hours per week.

The patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation shows the patient requires assistance with all ADLs (activities of daily living), except eating. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with locomotion, and phone use. She has bowel and bladder incontinence. Appeal statements indicate that the patient is homebound and requires assistance with all ADLs (activities of daily living). Her provider notes that the patient requires overnight assistance with toileting and turning. The information provide show that this patient has significant limitations in functioning and overnight needs that cannot be met with the approved CDPAP (consumer directed personal assistance program) 8.5 hours per day, 7 days per week, for a total of 59.5 hours per week. The increase in consumer directed personal assistance program (CDPAP) services for a total of 91 hours per week is medically necessary.