Appeal type: Medical necessity
Decision: Overturned

Diagnosis: osteoarthritis, hypertension, CKD (chronic kidney disease), PVD (peripheral vascular disease), foot drop, and spinal stenosis
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Service 12 Hours Per Day, 7 Days Per Week For A Total Of  84 Hours Per Week

The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) Service 12 Hours Per Day, 7 Days Per Week for a total of 84 Hours Per Week.

The denial is overturned.

The patient is a male. His medical conditions include osteoarthritis, hypertension, CKD (chronic kidney disease), PVD (peripheral vascular disease), foot drop, and spinal stenosis.  Denial of increase in Consumer Directed Personal Assistance Program (CDPAP) Service to 12 Hours Per Day, 7 days per week for a total of 84 hours per week, is being appealed.  He has been approved for CDPAP (Consumer Directed Personal Assistance Program) 6.5 hours per day, 7 days per week for a total of 45.5 hours per week.

The patient's UAS (Uniform Assessment System) evaluation completed shows minimally impaired cognition and requires assistance with all ADLs (activities of daily living) and IADLs (instrumental activities of daily living).  There was no significant change compared to UAS (Uniform Assessment System) evaluation completed previously. His condition has deteriorated since hospitalization a year ago.  His DME (durable medical equipment) includes cane, raised toilet seat, shower chair, shower grab bar, walker, wheelchair and incontinence supplies.

An appeal letter from the patient's children notes the patient has frequent day and nighttime needs.  It notes the patient has frequent falls that requires EMS (emergency medical service)/police for assistance getting up.  He was hospitalized twice approximately three months apart.  A night time log is provided and shows nighttime assistance with transferring to chair and bathroom, with assistance being provided every 1 to 2 hours.

Yes, the increase in consumer directed personal assistance program services to 84 hours per week is medically necessary.
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 Program (CDPAP) Service to 12 Hours Per Day, 7 days per week for a total of 84 hours per week is being appealed. The patient has been approved for CDPAP (Consumer Directed Personal Assistance Program) 6.5 hours per day, 7 days per week for a total of 45.5 hours per week.

This patient has multiple medical conditions and recent hospitalization after a fall. UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all ADLs/IADL (activities of daily living/instrumental activities of daily living). The patient has incontinence. He has frequent falls requiring assistance of EMS (emergency medical service)/police. The night log shows the patient requires assistance with transfers and toileting every 1 to 2 hours until midnight. The information provided supports that the patient needs assistance with ADLs (activities of daily living) beyond the approved 45.5 hours per week. The proposed increase in CDPAP (Consumer Directed Personal Assistance Program) to 12 Hours Per Day, 7 days per week for a total of 84 hours per week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.