Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Fractured right ankle
Treatment: Increase Consumer Directed Personal Assistance Service (CDPAS) From 51 Hours Per Week To 84 Hours Per Week, Pre-service (Health plan has approved 57 hours)
The insurer denied the Increase Consumer Directed Personal Assistance Service (CDPAS) From 51 Hours Per Week To 84 Hours Per Week, Pre-service (Health plan has approved 57 hours).
The denial is overturned, in part.

This male has epilepsy, autism spectrum disorder and status post ankle fracture. Psychological and neuropsychological evaluation shows the patient has impairments in all areas of cognitive functioning. He meets qualifications for intellectual disability. It is recommended that he live in a controlled environment with constant assistance. This is an appeal for denial of increase in Consumer Directed Personal Assistance Service (CDPAS) to 84 hours per week. The patient's brother is appealing because the patient cannot weight bear on right foot after fracture. He is using crutches. The patient's brother reports the patient needs help with cooking, cleaning, shopping, laundry, bathing, toileting, and dressing. The patient lives with his brother, who gives him medications and feeds him. He is sometimes incontinent of bowel and bladder. CDPAS hours were increased from 51 to 57 hours per week. 

Assessment performed shows severe mental delay and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with phone use, stair, transportation, and lower body dressing; extensive assistance with bathing, personal hygiene, upper body dressing, walking,  locomotion, toileting, and bed mobility; and limited assistance with eating. The patient has a cam walker boot and has to ambulate with crutches for 6-8 weeks. He is frequently incontinent of bowel and bladder. His brother notes the that the patient refuses to wear diapers and doesn't verbalize the need to use the toilet. Brother states the patient needs continuous monitoring because he gets scared throughout the day.

Yes, in part. The proposed treatment is medically necessary, in part.

Medically necessary services are those which are:
1) Safe 2) Effective 3) Generally accepted national standard of medical practice 4) Not provided primarily for convenience of the patient or the practitioner 5) The least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice, in part.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient, in part.

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 is an appeal for denial of 84 CDPAS (Consumer Directed Personal Assistance Service) hours per week. CDPAS hours were increased from 51 hours per week to 57 hours per week after the patient's provider requested an increase to 84 hours per week. The brother is appealing based on mobility limitations secondary to ankle fracture and need for continuous monitoring. He has a cam boot and ambulates with crutches. Assessment performed shows that the patient requires assistance with all ADLs (activities of daily living). He lives with his brother who provides support. PAS (Personal Assistance Service) is not indicated when there are no tasks being performed. The request to increase PAS hours to provide continuous monitoring does not support additional hours because PAS is not indicated for supervision. There has been a change in the patient's physical functioning as a result of his ankle fracture. The patient is not able to weight bear for 6-8 weeks after fracture. The proposed increase in PAS to a total 84 hours per week is not medically necessary. However, as a result of the recent limited mobility, an increase in PAS hours with 13 additional hours per week, for a total of 70 CDPAS hours per week is appropriate to support the additional mobility limitation.