Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, heart failure, coronary artery disease, COPD (Chronic Obstructive Pulmonary Disease)
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) Service for a Total Amount of 49 Hours per Week
The insurer denied: Increase Consumer Directed Personal Assistance Program (CDPAP) Service for a Total Amount of 49 Hours per Week
The denial is overturned

This elderly male patient has conditions including dementia, heart failure, coronary artery disease, and chronic obstructive pulmonary disease (COPD) on home oxygen.  The patient was admitted due to a chronic obstructive pulmonary disease (COPD) exacerbation.  He is appealing denial of increase consumer directed personal assistance program (CDPAP) service for a total amount of 49 hours per week.  The health plan approved 28 hours per week.  Uniform Assessment System (UAS) evaluation shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, phone use, and shopping; maximal assistance with managing medications; extensive assistance with stairs, transportation, bathing, lower body dressing, walking, locomotion, and toileting; limited assistance with personal hygiene, upper body dressing, and bed mobility;  and independent with eating.  The patient ambulates with a rollator.  He has occasional bladder incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with cognition, toilet transfer, walking, locomotion, and bed mobility.  A recent progress report notes the patient's memory and functional status are declining.  He is wheelchair bound.  He is completely dependent with all activities of daily living (ADLs).  The patient's daughter is the primarily care provider.  The patient needs more home health aide (HHA) hours to help with activities of daily living (ADLs).  Visit notes are provided supporting the need for assistance with activities of daily living as already outlined above.

The proposed treatment is medically necessary.
Personal assistance 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.  He is appealing denial of increase in consumer directed personal assistance program (CDPAP) service for a total amount of 49 hours per week.  The health plan approved 28 hours per week.  Uniform Assessment System (UAS) evaluation shows the patient needs assistance with all activities of daily living, except eating.  He has occasional bladder incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with cognition, toilet transfer, walking, locomotion, and bed mobility.  Records provided indicate the patient's memory and physical functioning are declining and he needs more assistance with activities of daily living.  This patient's physical cognitive and functioning are significantly impaired and have declined between Uniform Assessment System evaluations.  The need for assistance with all activities of daily living cannot be met with the approved consumer directed personal assistance program (CDPAP) 28 hours per week.  The proposed increase to 49 hours per week is medically necessary and appropriate.