Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, glaucoma, diabetes. 
Treatment: Increase Consumer Directed Personal Assistance 
Program (CDPAP) Services Live-in per diem: 1 day - 7 days per week - for a total amount of 91 hours per week. 
The insurer denied Increase CDPAP Services Live-in per diem: 1 day - 7 days per week - for a total amount of 91 hours per week. 
The denial is overturned. 

This patient is an elderly male patient with medical conditions that include a stroke with residual right-sided hemiparesis, hypertension, diabetes, glaucoma, and coronary artery disease. The denial of an increase in consumer-directed personal assistance program (CDPAP) services for a total amount of 91 hours per week is being appealed. The health plan approved a total of 49 hours per week. Uniform Assessment System (UAS) evaluation completed modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances and medications, phone use, shopping, bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility; and limited assistance with eating. The patient has frequent bowel and bladder incontinence. He uses a walker for ambulation. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with personal hygiene, toilet transfer, walking, locomotion, 
eating, and bed mobility. A letter from the Provider notes the patient needs 24/7 care due to motor deficits and need for assistance with activities of daily living (ADLs). A letter from another Provider notes the patient needs 24-hour assistance and requires hygiene and diaper changes on a regular basis. A letter from a third provider notes the patient has limitations with activities of daily living due to stroke. He cannot be left unattended due to need for frequent diaper changes and hygiene. 

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. This patient has multiple chronic conditions and had a recent stroke with residual hemiparesis. The denial of an increase in consumer directed personal assistance program (CDPAP) services for a total amount of 91 hours per week is being appealed. The health plan approved a total of 49 hours per week. Uniform Assessment System (UAS) evaluation completed 3 months ago shows the patient requires assistance with all activities of daily living (ADLs). Compared to Uniform Assessment System evaluation completed last year, there has been a decline with personal hygiene, toilet transfer, walking, locomotion, eating, and bed mobility. He has frequent bowel and bladder incontinence. 
Appeal statements note the patient needs 24-hour care due to physical limitations and need for frequent diaper changes and hygiene. The information provided shows that this patient has significant limitations in functioning that have declined. The approved consumer directed personal assistance program 49 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 91 hours per week is medically necessary.