Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, osteoarthritis, and chronic obstructive 
pulmonary disease
Treatment: Increase in Consumer Directed Personal Care 
Service (CDPAS) to 24 Hours per Day (Live-In)
The insurer denied: Increase in Consumer Directed Personal Care Service (CDPAS) to 24 Hours per Day (Live-In)
The denial is overturned.

This elderly female patient has medical conditions including stroke, hypertension, dementia, diabetes, coronary artery disease, osteoporosis, osteoarthritis, and chronic obstructive pulmonary disease. She is status post stroke associated with an arm and orbital fracture. After acute inpatient admission, she was transferred to a rehab facility. She is appealing denial of an increase in consumer directed personal care service (CDPAS) to 24 hours per day (live-in). The health plan approved 56 hours per week. Uniform Assessment System (UAS) evaluation completed on recently shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing medications, shopping, bathing, personal hygiene, and dressing; maximal assistance with transportation, walking, locomotion, toileting, and bed mobility; and extensive assistance with eating. She has bowel and bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation completed six months prior, there has been a decline in all areas of functional status. The patient's child notes the patient has declining mental health. She has been admitted to a nursing home. She needs help eating, need assistance with ambulation, and has a stage III 
decubitus ulcer. She needs help with activities of daily living (ADLs), including assistance going to bed. A letter from the patient's doctor notes the patient has completed rehab (rehabilitation). The patient requires limited assistance with activities of daily living and ambulation with a rolling walker. Twenty-four hours seven days per week (24/7) live in assistance is recommended for a safe discharge from rehab.

The proposed treatment is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding. 

This patient has multiple chronic conditions and has a history of recent stroke and fall that resulted in hospitalization and rehab. She is appealing denial of increase in consumer directed personal care service (CDPAS) to 24 hours per day (live-in). The health plan approved 56 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows the patient requires maximal assistance to total dependence with all activities of daily living, except for extensive assistance with eating. She has bladder and bowel incontinence. Compared to Uniform Assessment System (UAS) evaluation completed 6 months prior, there has been a decline in all areas of functional status. The appeal statements support the need for assistance 
with activities of daily living as noted above. In addition, the patient has a decubitus ulcer. This patient has significant impairments. The need for assistance with all activities of daily living cannot be met with the approved consumer directed personal assistance services (CDPAS) 56 hours per week. The approved hours are insufficient to meet this patient's needs. The proposed increase in consumer directed personal assistance services (CDPAS) to 24 hours per day (live-in) is medically necessary and appropriate.