Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Stroke.
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services For A Total Amount of 168 Hours Per Week.

The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) Services For A Total Amount of 168 Hours Per Week.  The denial is upheld.

The patient is a female. Her conditions include stroke with residual left-sided hemiplegia. The patient lives alone. Her daughter is PA (personal assistant). Her granddaughter and daughter assist during non-service hours. Denial of increase Consumer Directed Personal Assistance Program (CDPAP) Services for a total amount of 168 hours per week is being appealed. The Plan approved CDPAP (Consumer Directed Personal Assistance Program) 8.5 hours per day, 7 days a week for a total of 59.5 hours per week.

UAS (Uniform Assessment System) evaluation completed shows moderately impaired cognition and functional status: total dependence with housework, managing finances and medication, and shopping; maximal assistance with meal preparation, phone use, bathing, lower body dressing, walking, locomotion, toileting, and bed mobility; and extensive assistance with personal hygiene, upper body dressing, and eating. She has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed there is no significant change in functional status. Patient has PERS (personal emergency response system), walker, wheelchair, commode, shower grab bar, shower chair, liners, pullups and underpads.

An appeal letter from the provider notes the patient is in constant need of supervision due to her hemiplegia and being non-cognizant of disability resulting in frequent falls.

No, the Increase Consumer Directed Personal Assistance Program (CDPAP) Services For A Total Amount of 168 Hours Per Week is not medically necessary.

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. Denial of increase Consumer Directed Personal Assistance Program (CDPAP) Services for a total amount of 168 hours per week is being appealed. The Plan approved CDPAP (Consumer Directed Personal Assistance Program) 8.5 hours per day, 7 days a week for a total of 59.5 hours per week.

The patient has several chronic conditions, including status post stroke with residual left-sided hemiplegia. Her daughter is her PA (personal assistant), and her granddaughter and daughter provide informal support. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living). Compared to UAS (Uniform Assessment System) evaluation completed, there is no significant change in functional status. Appeal statement notes the patient needs constant supervision and frequent falls because of being noncognizant of her hemiplegia. Personal Care Services are not indicated for supervision. Per UAS (Uniform Assessment System) evaluations, there has been no significant change in the patient's functional status. Additional CDPAP (Consumer Directed Personal Assistance Program) hours are primarily requested for supervision. Based on the patient's functional status and support provided by family, the approved CDPAP (Consumer Directed Personal Assistance Program) services for a total of 59.5 hours per week is sufficient to meet the patient's needs for assistance with ADLs (activities of daily living). The proposed CDPAP (Consumer Directed Personal Assistance Program) services for a total amount of 168 hours per week is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.