Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, hypertension, diabetes and coronary artery disease.
Treatment:  Increase Consumer Directed Personal Assistance Services (CDPAS) to 24 Hours per Day, 7 Days per Week (Live-in) for a Total of 91 Hours.

The insurer denied the Increase Consumer Directed Personal Assistance Services (CDPAS) to 24 Hours per Day, 7 Days per Week (Live-in) for a Total of 91 Hours.  The denial is overturned.

This elderly female has dementia, hypertension, diabetes and coronary artery disease. The denial of an increase in consumer directed personal assistance services (CDPAS) to 24 hours per day, 7 days per week (live-in), for a total of 91 hours is being appealed. The health plan approved consumer directed personal assistance services of 42 hours a week. Uniform Assessment System evaluation completed 2 months ago shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, transportation, and toileting; extensive assistance with managing finances and medication, phone use, bathing, lower body dressing, walking, and locomotion; and limited assistance with personal hygiene, upper body dressing, bed mobility, and eating. She has bowel and bladder incontinence. A statement from her Provider notes the patient was admitted to rehab 3 months ago due to a decline in ambulatory status. She requires assistance with all activities of daily living (ADLs) and personal care. She ambulates 30 feet with assistance and a rolling walker. She is confused and at risk for falls. A letter from the patient's daughter notes that the patient's health has deteriorated. She is bed and wheelchair bound. She is a high risk for fall. She needs assistance with activities of daily living.

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. The denial of an increase in consumer directed personal assistance services (CDPAS) 24 hours a day, 7 days a week (live in), for a total of 91 hours is being appealed. The health plan approved consumer directed personal assistance services 42 hours a week. Uniform Assessment System evaluation completed 2 months ago shows the patient requires assistance with all activities of daily living. She is incontinent of bowel and bladder. Appeal statements note that the patient's cognitive and functional status have declined. The statements support her need for assistance with all activities of daily living. She had a short-term rehab stay due to decline in ambulatory status. The information provide show that this patient has significant limitations in functioning. Her impairments and level of need for assistance with activities of daily living cannot be met with the approved consumer directed personal assistance services 42 hours a week. The proposed increase consumer directed personal assistance services to 24 hours a day, 7 days a week (live in), for a total of 91 hours is medically necessary.