Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ASCVD (atherosclerotic cardiovascular disease), post traumatic neuralgia, osteoarthritis, CAD (coronary artery disease), and diabetes
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Services, For A Total of Amount of 42 Hours Per Week
The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP) Services, For A Total of Amount of 42 Hours Per Week.
The denial is upheld.

The patient is a male. His medical conditions include ASCVD (atherosclerotic cardiovascular disease), post traumatic neuralgia, osteoarthritis, CAD (coronary artery disease), and diabetes. The patient lives with his ex-wife. A member of the patient's family is PA (personal assistant), and a friend is back-up PA (personal assistant). The patient's son assists with ADLs/IADLs (activities of daily living/instrumental activities of daily living) on weekends. Denial of increase in Consumer Directed Personal Assistance Program (CDPAP) services, for a total of amount of 42 hours per week, is being appealed. The health plan approved 35 hours/week.

The patient's UAS (Uniform Assessment System) evaluation completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, and shopping; extensive assistance with bathing, lower body dressing, walking, locomotion, and toilet transfer; limited assistance with managing finances, personal hygiene, upper body dressing, toilet use, and bed mobility; independent with eating; and supervision with managing medications. He has occasional bladder incontinence. There is no significant change from UAS (Uniform Assessment System) evaluation completed previously.

No, the Increase in Consumer Directed Personal Assistance Program (CDPAP) Services, For A Total of Amount of 42 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 of amount of 42 hours per week, is being appealed. The health plan approved 35 hours/week.

The patient has several chronic conditions. His son assists with ADLs/IADLs (activities of daily living/instrumental activities of daily living) on weekends. UAS (Uniform Assessment System) evaluation completed shows the patient requires extensive to maximal assistance with meal preparation, shopping, bathing, lower body dressing, walking, locomotion, and toilet transfer; and limited assistance with managing finances, personal hygiene, upper body dressing, toilet use, and bed mobility. He has occasional bladder incontinence. There is no significant change from UAS (Uniform Assessment System) evaluation completed previously. There is no additional documentation supporting the medical necessity for additional hours. Based on all available information, the approved CDPAP (Consumer Directed Personal Assistance Program) 35 hours/week is sufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed increase in CDPAP (Consumer Directed Personal Assistance Program) services for a total of amount of 42 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.