Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance Service
(CDPAS): 112 Hours per Week (16 Hours per Day, 7 Days per Week)
The insurer denied: Consumer Directed Personal Assistance Service (CDPAS): 112 Hours per Week (16 Hours per Day, 7 Days per Week)
The denial is overturned.

The patient is an elderly female with a history of general debility due to dementia. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 91 hours per week (13 hours per day, 7 days a week) based on Uniform Assessment System (UAS) evaluation of last year to 112 hours per week (16 hours per day, 7 days a week). The health plan denied the request because the patient has her daughter living with her as an aide and is never alone, she knows who she is, she is able to walk with a walker, she has no wounds or other skin conditions, and she needs help with meal preparation, housekeeping, shopping, finances, medications, medical appointments, bathing, hygiene, dressing, locomotion, toileting, 
transfers, bed mobility, and eating. These conditions are already known and included in the previous decision. The additional hours requested are because the patient's daughter works full-time and the patient needs additional assistance as she has chronic medical conditions with her health declining, unsteady gait making her high-risk falls, bilateral knee pain, shortness of breath, and she is dependent on others for her activities of daily living (ADLs) including meal preparation, dressing, toilet transfer, bed mobility (That is (i.e.) most activities of daily living), etc. She is also unsafe to be left alone. A review of the records showed that the patient has multiple chronic medical conditions including Alzheimer's disease, aortic valve stenosis, congestive heart failure (CHF), hypertension, hyperlipidemia, knee osteoarthritis, etc. Uniform Assessment System - New York (UAS-NY) evaluation of 4 months ago showed that the patient is moderately cognitively impaired, and requires extensive assistance with personal hygiene, upper body dressing, eating, bed mobility, maximum assistance for managing medications, phone use, transportation, lower body dressing, walking, toilet use, bathing, locomotion, toilet transfer, and totally dependent for housework, meal preparation, managing finances, shopping, etc. Her family support is good as she lives with her daughter who acts as an 
aide.

The requested health service is medically necessary.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 91 hours per week based on Uniform Assessment System (UAS) evaluation of last year to 112 hours per week is medically necessary because based on the most recent Uniform Assessment System evaluation of 4 months ago, the patient is moderately cognitively impaired, requires extensive assistance with personal hygiene, upper body dressing, eating, bed mobility, maximum assistance for managing medications, phone use, transportation, lower body dressing, walking, toilet use, bathing, locomotion, toilet transfer, and totally dependent for housework, meal preparation, managing finances, shopping, etc. The patient's family support is good as she lives with her daughter who acts as an aide. 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 evaluation of 4 months ago as stated above. Therefore, the 112 hours per week based on Uniform Assessment System evaluation of 4 months ago requested should be approved.