Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Stroke
Treatment: Home Health Care- CDPAS (consumer directed personal assistance services) 24 hours live-in care.
The health plan denied the CDPAS consumer directed personal assistance services 24hrs. live in care as not medically necessary. The reviewer has overturned in whole the health plan's determination.

This is a case review for a female with medical history notable for prior ischemic stroke, urinary incontinence, coronary heart disease, diabetes, heart failure with preserved ejection fraction, atrial fibrillation, sleep apnea, dysphasia, and arthritis. The patient is approved for 35 hours per week of consumer directed personal assistance services. The patient and her care team requested an increase to 24 hour live in personal care, and this request was denied by the health plan. This denial is the subject under review.
The patient's physician provided a letter of support for this appeal. The letter states that the patient suffers sequelae of her previous stroke including hemiparesis and dysphasia. She requires assistance performing activities of daily living such as toileting and laundry. Arthritis further limits her range of motion. She ambulates with a walker or with a motorized scooter but still requires supervision to prevent falls.
The patient's neurologist provided a letter of support. The letter states that the patient has a history of strokes. She has resulting cognitive impairment and motor deficits which impact her mobility. The physician requests 24-hour live-in care.
The patient's child provided a letter of support for this appeal. The letter states that the health plan's denial letter indicates that the child lives with the patient; the letter clarifies this information as incorrect. Furthermore, the child has a full-time job. They are not able to provide informal assistance for the patient.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient's cognition was described as minimally impaired. She was alert and oriented to person and place only with periods of forgetfulness. Her short-term memory was impaired. For her instrumental activities of daily living, she requires total dependence for housework and stairs. She requires maximal assistance for meal preparation, finances, transportation, shopping, and medications. For her activities of daily living, the patient requires maximal assistance for dressing lower body. She requires extensive assistance with bathing, hygiene, dressing upper body, toilet transfer, toilet use, and bed mobility. She requires limited assistance for walking. She is frequently incontinent of urine. She is continent of stool. She wears Pull-Ups for incontinence care.
The requested health service of Consumer Directed Personal Assistance Services (CDPAS) 24 hrs. live in care is medically necessary for this patient.
The patient requires hands-on assistance for all activities of daily living including ambulation, transfers, toileting, and management of incontinence care products. This need is reflected in the UAS (Uniform Assessment System) as well as in the physician letters. Because these needs can be expected to be continuous and unscheduled throughout the day and occasionally at nighttime as well, a live-in personal care aide is medically necessary and appropriate for the patient. Failure to support her personal care needs could result in falls, skin breakdown, and/or infection.