Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular dementia, major depression, diabetes, urinary incontinence
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAS) Services for a Total of 50 Hours per Week.
The insurer denied: Increase Consumer Directed Personal Assistance Program (CDPAS) Services for a Total of 50 Hours per Week.
The denial is overturned.

The patient is an elderly female with a history of general debility due to dementia. The request was for Consumer Directed Personal Assistance Program (CDPAP) to be increased from 
44 hours per week based on Uniform Assessment System (UAS) of last year to 50 hours per week. The health plan denied the request because the patient's abilities to perform her activities of daily living have stayed the same for upper/lower body dressing, personal hygiene, bed mobility, walking, locomotion, bathing, toilet transfer, toilet use, eating, meal preparation, medication management, and housework, etc. These conditions are already known and included in the previous decision. The additional hours requested are because the patient cannot be left alone and needs additional assistance; has chronic medical conditions with her health declining; is a high risk for falls, bilateral knee pain, and shortness of breath; and is totally dependent for housework, meal preparation, managing finances, shopping, managing medications, etc. She is also unsafe to be left alone. A review of the records showed that the patient has multiple chronic medical conditions including vascular dementia, major depression, diabetes, urinary incontinence, etc. Uniform Assessment System-New York (UAS-NY) evaluation of 5 months ago showed that the 
patient is moderately cognitively impaired; limited assistance for personal hygiene, upper body dressing, lower body dressing, walking, locomotion, toilet transfer, toilet use, bathing, bed mobility, eating; and totally dependent on housework, meal preparation, managing finances, shopping, managing medications, etc. Her family support is good as she lives with her daughter, son-in-law, and four grandchildren.

The requested health service is medically necessary.

The requested increase for Consumer Directed Personal Assistance Program (CDPAP) from 44 hours per week based on Uniform Assessment System (UAS) of last year to 50 hours per 
week is medically necessary because based on the most recent Uniform Assessment System of 5 months ago the patient is moderately cognitively impaired; limited assistance for personal hygiene, upper body dressing, lower body dressing, walking, locomotion, toilet transfer, toilet use, bathing, bed mobility, eating; and totally dependent for housework, meal preparation, managing finances, shopping, managing medications, etc. Her family support is good as she lives with her daughter, son-in-law, and four grandchildren. The reason for denial by the health plan as stated in the clinical information above does not align with the patient's disability features as stated in the Uniform Assessment System of 5 months ago as stated above. Therefore, the 50 hours per week based on Uniform Assessment System of 5 months ago should be approved.