Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, carpal tunnel syndrome, hypertension, chronic pain, abnormal gait, dizziness, osteoporosis, hearing loss, urinary incontinence, and breast cancer.  

Treatment: Consumer and Self Directed Personal Assistance Services - 35 Hours per Week. 

The insurer denied the Consumer and Self Directed Personal Assistance Services - 35 Hours per Week. 

The denial is overturned. 

This female patient has conditions including heart disease, carpal tunnel syndrome, hypertension, chronic pain, abnormal gait, dizziness, osteoporosis, hearing loss, urinary incontinence, and breast cancer.  She lives alone.  She is appealing denial of Consumer and Self Directed Personal Assistance Services (CDPAS) 35 hours per week.  The plan approved 16 hours per week.  Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: maximal assistance with meal preparation, and housework; extensive assistance with managing medications, stairs, shopping, and transportation; limited assistance with bathing; supervision with managing finances, walking, locomotion, and toileting; and independent with personal hygiene, upper body dressing, bed mobility, and eating.  She has occasional bladder incontinence. 

A letter from the provider notes the patient has had a memory and functional decline.  She is limited in performing activities of daily living (ADLs) due to movement limitations.  She has more frequent disorientation and forgetfulness. 

A letter from the patient's daughter notes the patient's function and mental status have declined.  The patient needs assistance with activities of daily living (ADLs).  The letter notes the patient needs assistance with activities of daily living (ADLs), including with ambulation.  The family has arranged for services beyond the approved 16 hours, but this care is no longer available. 

Yes, the Consumer and Self Directed Personal Assistance Services - 35 Hours per Week is 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.  This patient has multiple chronic conditions.  She is appealing denial of consumer directed personal assistance services (CDPAS) - 35 hours per week.  The plan approved 16 hours per week.  

Uniform Assessment System evaluation completed shows the patient requires assistance with meal preparation, housework, managing medications, stairs, shopping, transportation, and bathing.  She has occasional bladder incontinence.  The appeal statements note there has been deterioration in the patient's mental and functional status.  This patient has functional limitations that have declined.  It is noted that the patient now needs assistance with ambulation.  Due to the patient's needs for assistance with activities of daily living, deterioration in the patient's functional status and loss of informal support, the approved consumer directed personal assistance services - 16 hours per week is inadequate to meet the patient's needs.  The proposed consumer directed personal assistance services - 35 hours per week is medically necessary to meet the patient's needs for assistance with activities of daily living and personal care.  

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