Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, hip pain, dizziness and giddiness, and gout
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) to 7 Days Per Week, 8 Hours per Day for 56 Hours per week
The insurer denied: Increase Consumer Directed Personal Assistance Services (CDPAS) to 7 Days Per Week, 8 Hours per Day for 56 Hours per week
The denial is overturned.

The patient is an elderly female. Her medical conditions include arthritis, hip pain, dizziness and giddiness, and gout. She lives alone. Denial of increase consumer directed personal assistance services (CDPAS) to seven days per week, eight hours per day for 56 hours per week is being appealed. The health plan approved increase seven days per week, five hours per day, 
for a total of 35 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed on 4 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, managing finances, and shopping; maximal assistance with housework; extensive assistance with managing medications, phone use, bathing, lower body dressing, and toilet use; limited assistance with personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and eating; and independent with bed mobility. She has occasional bladder incontinence. An appeal statement notes the patient needs assistance with activities of daily living (ADLs) with a decline in her functioning over the past 90 days. The patient ambulates with a walker and has had a fall in 6 months ago. She has unscheduled needs throughout the day, such as transferring, walking, repositioning, and tolerating as supported by logs. A letter from the patient's provider notes the patient's condition has progressed over the past six months and is severely limiting her activities of daily living. The patient ambulates with a walker and has a history of falls. She requires constant assistance at home. A letter from another provider notes the patient has major depressive disorder, generalized anxiety disorder, chronic insomnia, and cognitive impairment. She needs assistance with activities of daily living.

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. Denial of increase consumer directed personal assistance services (CDPAS) to seven days per week, eight hours per day for 56 hours per week is being appealed. The health plan approved seven days per week, five hours per day, for a total of 35 hours per week. This patient has multiple chronic conditions. She lives alone. Uniform Assessment System 
(UAS) evaluation completed 4 months ago shows she needs assistance with all activities of daily living, except bed mobility. She has bladder incontinence. Appeal statements report that there has been a decline over the past 90 days with the patient's functioning. She requires assistance for ambulation with a walker. She has unscheduled needs throughout the day, such as 
transferring, walking, repositioning, and tolerating as supported by logs. Her limitations and needs for assistance with activities of daily living cannot be met with the approved consumer directed personal assistance services (CDPAS) 35 hours per week. The requested increase CDPAS (consumer directed personal assistance service) to 56 hours per day is medically necessary.