Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic pain, fibromyalgia, scoliosis and myositis.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) Level 6 - 7 Days per Week, 12 Hours per Day, 84 Hours Per Week, Pre-service.
The insurer denied the Consumer Directed Personal Assistance Services (CDPAS) Level 6 - 7 Days per Week, 12 Hours per Day, 84 Hours Per Week, Pre-service.
The denial is overturned. 

This patient is a female with conditions including chronic pain, fibromyalgia, scoliosis and myositis.  She is wheelchair bound and lives alone in a ground level apartment.  Her mother and mother's friend live in the second floor apartment.  She is appealing the denial of consumer directed personal assistance services (CDPAS) 84 hours per week.  She was partially approved for an increase in consumer directed personal assistance services (CDPAS) from 16 to 21 hours per week.  

Uniform Assessment System (UAS) evaluation completed showed modified independent cognition and functional status: maximal assistance with meal preparation and housework; extensive assistance with managing medications, bathing, lower body dressing, and locomotion; limited assistance with upper body dressing, walking, toileting and eating; and independent with managing finances, phone use, personal hygiene and bed mobility.  Her activity level is less than one hour per day.  She is able to use a walker for short distances.  She is occasionally incontinent of urine.  

Physician reports indicate the patient needs assistance with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation.  It states she needs 10 to 12 hours more and she needs assistance with nighttime urination.  It states it is unsafe for the patient to remain in a diaper all night due to skin breakdown.  It notes 21 hours is insufficient.

Yes, the proposed treatment is medically necessary.
This request is consistent with standard of care.

Personal Care 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 medical conditions and is wheelchair bound.  She is appealing denial of consumer directed personal assistance services (CDPAS) 84 hours per week.  She has been approved for consumer directed personal assistance services for 21 hours per week.  The Uniform Assessment System (UAS) evaluation completed shows the patient needs assistance with meal preparation, housework, managing medications, bathing, lower body dressing, locomotion, upper body dressing, walking, toileting and eating.  She performs independently with managing finances, phone use, personal hygiene and bed mobility.  She is incontinent of urine.  The appeal letter notes the patient needs assistance with activities of daily living (ADLs) as well as nighttime urination.  It notes it is unsafe for the patient to remain in a diaper all night.  This patient has significant limitations with walking and toileting.  The approved 21 hours per week are insufficient to meet the patient's needs for assistance with activities of daily living and personal care, including assistance with toileting.  The proposed increase in consumer directed personal assistance services to a total 84 hours per week is medically necessary to meets this patient's needs.