Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: 84 hours per week consumer directed personal assistance services (CDPAS) level 2
The insurer denied 84 hours per week consumer directed personal assistance services (CDPAS) level 2.
The determination is upheld.

This is a male patient with a medical history notable for dementia. The patient is approved for 35 hours per week of level 2 consumer directed personal assistance services. The patient and his care team requested an increase to 84 hours per week, and the request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The patient has coronary artery disease, hypertension, diabetes, hypothyroidism, dementia, anxiety, depression, arthritis, and urinary incontinence. The physician states that he needs assistance with chores due to fatigue and joint pain. The note states that due to deterioration of the patient's status that his current home care services are no longer sufficient and the requested increase will "ensure the stability of his clinical status." There is no discussion regarding what personal care needs are not currently being met.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives in an apartment with his wife. He was alert and oriented times three. Despite a dementia diagnosis, he is able to call for help and direct his own care. For his Instrumental activities of daily living (IADLs), he requires total dependence for housework. He requires maximal assistance for meal preparation, phone use, and shopping. He requires extensive assistance for medications and stairs. For his activities of daily living (ADLs), he requires extensive assistance for bathing and dressing lower body and limited assistance for all others. He is continent of urine and stool. A task tool associated with the assessment recommended 24.5 hours per week to address his personal care needs. Compared to a prior assessment, he did not show a significant decline in activities of daily living (ADL) functioning.
The patient's health plan provided a summary of the case review notes and appeal. The patient is a mutual case with his wife, who currently receives 84 hours per week. They state that the prior two independent evaluations did not demonstrate a need for more than 24.5 hours per week and he is currently approved for 35 hours per week. Because this is a mutual case with his wife, there is some overlap in terms of household tasks that would allow for further flexibility. His hours are consumer directed and can be used at whichever time of day would be most beneficial. At issue is the medical necessity of 84 hours per week of consumer directed personal assistance services (CDPAS) level 2.

The requested health service of 84 hours per week consumer directed personal assistance services (CDPAS) level 2 has not been demonstrated to be medically necessary for this patient.
The patient has some functional limitations as outlined in the UAS which primarily revolve around IADLs. He is receiving 35 hours per week, which is 10 hours more than was recommended by the UAS task tool. His hours are consumer directed and can be used when desired by the patient. It is unclear which personal care needs, if any, are not being met at his current allotment of personal care hours. There is no clearly demonstrated medical necessity for the requested increase in personal care hours.