Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, CAD (coronary artery disease), Ehlers-Danlos syndrome, chronic kidney disease, osteoarthritis, hypothyroidism, depression, anxiety, peripheral vascular disease, hyperlipidemia, and bladder/bowel incontinence.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 24-Hour (live-in).

The insurer denied: Consumer Directed Personal Assistance Services (CDPAS) 24-Hour (live-in).  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 Services (CDPAS) to be increased from 35 hours per week (7 hours per day, 7 days per week) to 24 hours per day, 7 days per week, live-in, based on UAS (Uniform Assessment System) evaluation of 5 months ago. The health plan denied coverage of the request, noting that the patient has a supportive family who can direct her care and ensure that she is not alone and already paying a private aide to live with her. She is alert and oriented to person and place, able to make her needs known, express an emergency plan, etc. The health plan notes that the current approved hours are adequate to meet the patient's needs. The additional hours requested are because of the patient's chronic medical conditions, and to help with her Activities of Daily Living (ADLs), as she requires extensive assistance with most of her ADLs (activities of daily living), along with being high risk for falls and having moderate cognitive deficit due to dementia. A review of the records showed that the patient has multiple chronic medical conditions, including dementia, CAD (coronary artery disease), Ehlers-Danlos syndrome, chronic kidney disease, osteoarthritis, hypothyroidism, depression, anxiety, peripheral vascular disease, hyperlipidemia, and bladder/bowel incontinence. She is also a high risk for falls. The patient's UAS (Uniform Assessment System) evaluation of 5 months ago showed that she is moderately cognitively impaired with decisions consistently poor or unsafe, requires limited assistance with walking, locomotion, eating, extensive assistance with personal hygiene, upper body dressing, toilet transfer, maximal assistance for managing medications, phone use, transportation, bathing, lower body dressing, toilet use, and totally dependent for meal preparation, housework, managing finances, and shopping. The patient lives in a two-bedroom apartment with an aide.

The Consumer Directed Personal Assistance Services (CDPAS) 24 Hour (live - in) is medically necessary.

The patient is moderately cognitively impaired with decisions consistently poor or unsafe. She requires limited assistance with walking, locomotion, eating, extensive assistance with personal hygiene, upper body dressing, toilet transfer, maximal assistance for managing medications, phone use, transportation, bathing, lower body dressing, and toilet use. She is totally dependent for meal preparation, housework, managing finances, and shopping. She is also at high risk for falls. The reason for denial by the health plan as noted in the clinical information above, does not align with the patient's disability features as noted in the UAS (Uniform Assessment System) evaluation of 5 months ago.
Therefore, given the above, the requested Consumer Directed Personal Assistance Services (CDPAS) 24-Hour (live-in) is medically necessary is medically necessary.