Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ataxia/Inability to coordinate voluntary muscular movements
Treatment: Consumer Directed Personal Assistance Services (CDPAS) Level 2: 55 Hours per Week
The health plan denied Consumer Directed Personal Assistance Services (CDPAS) Level 2: 55 Hours per Week.
The determination is Upheld.

This is a case review for a male with medical history notable for ataxic gait, fall risk, and dizziness. The patient is approved for 30 hours per week of consumer directed personal assistance services. The patient and his care team requested an increase to 55 hours per week, and the request was partially approved, with an increase to 35 hours per week. The denial of 55 hours per week is the subject under review.
A Uniform Assessment System was completed in person. The patient lives in a home with his spouse. The patient was alert and oriented but forgetful at times. He is able to make decisions and call 911 in the event of an emergency. For his instrumental activities of daily living, the patient requires total dependence for housework. He requires maximal assistance for shopping and meal preparation. He requires extensive assistance for stairs and transportation. For his activities of daily living, he requires extensive assistance for bathing and dressing his lower body. He requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. He is independent for bed mobility, and eating. He was observed ambulating with a slow and unsteady gait. He uses one person assistance when ambulating outdoors. The patient reported a decline in ambulation with increased weakness and dizziness following a recent hospitalization. His spouse returns from work in the evening, and he does not have personal care assistance for the entire time that his spouse is gone. He is continent of urine and stool. There were two or more falls in the previous 30 days. There was no pressure ulcer present. Compared to a prior assessment, the patient experienced a modest decline in activities of daily living functional status.
The patient's physician provided a letter of support for this appeal. The letter states that he is being treated for hypertension, atrial fibrillation, and syncope with multiple recent falls. The physician requests an increase to 50 hours per week to prevent falls. No further detail was provided.

The requested health service of Consumer Directed Personal Assistance Services (CDPAS) Level 2: 55 Hours per Week has not been clearly demonstrated to be medically necessary for this patient.
The patient requires some assistance with activities of daily living. He is prone to falls due to dizziness. He requires assistance with ambulating for longer distances outdoors. The provided documentation does not demonstrate that the patient requires continuous personal care. He was approved for an increase to 35 hours per week, which should lessen the amount of time that he is left alone during the day. His wife is otherwise available after work each day. There is no documentation regarding what personal care needs, if any, would be unmet at his recently approved increase to 35 hours per week. Therefore, the requested increase has not been demonstrated to be medically necessary for the patient.