Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legal blindness, hypertension, vertigo, and chronic shoulder pain.
Treatment: Increase Consumer Directed Personal Care. Assistant Services To 12 Hours Per Day 7 Days Per Week (Monday through Sunday) Total of 84 Hours per week
The insurer denied: Increase Consumer Directed Personal Care. 
Assistant Services To 12 Hours Per Day 7 Days Per Week (Monday through Sunday) Total of 84 Hours per week.
The denial is overturned.

The patient is an adult female. Her conditions include legal blindness, hypertension, vertigo, and chronic shoulder pain. She lives with her brother. Denial of increase consumer directed personal care assistant services (CDPAS) to 12 hours per day, 7 days per week (Monday through Sunday) for a total of 84 hours per week, is being appealed. The health plan approved CDPAS (consumer directed personal assistant services) 8 hours per day, 7 days per week (Monday through Sunday) for a total of 56 hours per week. Uniform Assessment System (UAS) evaluation completed on this year shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, and phone use; extensive assistance with bathing, lower body dressing, and toilet transfer; limited assistance with personal hygiene, upper body dressing, walking, locomotion, toilet use; and eating; and independent with bed mobility. The patient ambulates with a cane. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been no decline with functional status. An appeal statement notes the patient is homebound. Her hearing has decompensated so that she can no longer compensate for vision loss. She is at increased risk for falls due to vertigo. An increase in CDPAS (consumer directed personal assistant service) is indicated due to the patient's advanced age and multiple medical conditions. A statement from the patient's provider notes the patient's medical conditions are degenerative. She is unable to use a support cane for ambulation and requires assistance. The patient is left without assistance from 4 PM to 8 AM the next day. She has unscheduled needs that include toileting, transferring and ambulation. Additional information includes medical records and daily logs show the need for assistance from 8 AM to 9:30 PM.

The requested Increase Consumer Directed Personal Care Assistant Services To 12 Hours Per Day 7 Days Per Week (Monday through Sunday) Total of 84 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. Denial of increase consumer directed personal care assistant services (CDPAS) to 12 hours per day, 7 days per week (Monday through Sunday) for a total of 84 hours per week, is being appealed. The health plan approved CDPAS (consumer directed personal assistant services) 56 hours per week. This patient has multiple chronic conditions, and she is legally blind. Uniform Assessment System (UAS) evaluation completed this year shows she requires assistance with all ADLs (activities of daily living), except bed mobility. The appeal statements support the patient has multiple chronic medical conditions and needs assistance with all ADLs (activities of daily living). She is noted to be homebound. The patient has day and night needs that are supported by the daily logs. The information provided shows that this patient has significant limitations in functioning that occur during the day and night. The patient's need cannot be met with the approved CDPAS (consumerdirected personal assistant services) 56 hours per week. The requested CDPAS (consumer directed personal assistant services) 84 hours per week is medically necessary.