Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis arthritis, heart failure, breast cancer, 
neuromuscular disorder
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) to 56 Hours per Week
The insurer denied: Increase Consumer Directed Personal Assistance Services (CDPAS) to 56 Hours per Week
The denial is upheld.

This elderly female patient has medical conditions that include breast cancer, neuromuscular disorder, lumbar disc degeneration, osteoporosis, osteoporosis arthritis, heart failure, and major depression disorder. She lives alone. Her niece lives on the 2nd floor and sister in the basement. The denial of an increase in consumer directed personal assistance services (CDPAS) to 56 hours per week is being appealed. The plan approved consumer directed personal assistance services, 
48 hours per week. The patient is reported to have recent falls and unable to stand without full assistance. Uniform Assessment System (UAS) evaluation completed several months ago shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, stairs, shopping, bathing, lower body dressing, and toilet use; extensive assistance with managing medications, phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and bed mobility; limited assistance with eating; and supervision with managing finances. There has been a deterioration in the patient's health since a fall some months ago. The patient has bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with housework, phone use, and bed mobility. A letter from the Provider notes the patient has a history of multiple falls and recent fracture of the right hand that requires a brace.

The requested health service is not 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. This patient has multiple chronic conditions and a recent fall resulting in right hand fracture treated with a brace. This patient is appealing the denial of an increase in consumer directed personal assistance services (CDPAS) to 56 hours per week. The plan approved consumer directed personal assistance services, 48 hours per week. Uniform Assessment System (UAS) evaluation completed several months ago shows the patient requires assistance with all activities of daily living. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with housework to total dependence, and phone use and bed mobility to extensive assistance. Appeal statements note the patient has a history of falls and recent hand fracture. The information provided does not support that the patient has a significant deterioration in functional needs that require an increase in consumer directed personal assistance services from 48 to 56 hours per week. The patient is able to schedule services according to her needs that can continue to be met with the approved 48 hours per week. The approved consumer directed personal assistance services 48 hours per week is appropriate to meet this patient's needs for assistance with activities of daily living. The proposed consumer directed personal assistance services 56 hours per week is not indicated.