Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis, Urinary Incontinence
Treatment: Consumer Directed Personal Assistance Program (CDPAP), 12 hours per day 7 day(s) per week a total of 84 hours per week
The insurer denied the request for Consumer Directed Personal Assistance Program (CDPAP), 12 hours per day 7 day(s) per week for a total of 84 hours per week.
The health plan's determination is upheld.

The patient is a female with a medical history notable for multiple sclerosis and urinary incontinence. The patient is approved for 4.5 hours per day, 7 days per week (31.5 hours per week) for the CDPAP. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan. 
The patient lives with her family, and she also has a supportive friend. The request was submitted because "her walking has gotten worse and her chronic condition has made her weaker." The request is for help with housework, laundry, shopping, meal preparation, and walking.
A letter of support for this appeal was provided by the patient's attorney and was reviewed in detail. There were no letters of medical necessity provided as a part of this appeal.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert and oriented times three with periods of forgetfulness noted. She is able to direct her own care and call for help in an emergency. For her instrumental activities of daily living (IADL's), she requires total dependence for housework. She requires maximal assistance with meal preparation and shopping. She requires extensive assistance with stairs and managing finances. For her activities of daily living (ADL's), she requires extensive assistance with bathing and dressing lower body. All other ADL's are supervision only or independent. She ambulates and transfers with the assistance of a cane. She is frequently incontinent of urine with daily occurrences. A task tool associated with the UAS recommended 3.5 hours per day to address her functional needs. Compared with a prior UAS, there was no significant change in her cognitive or functional status.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service of Consumer Directed Personal Assistance Program (CDPAP), 12 hours per day 7 day(s) per week for a total of 84 hours per week is not medically necessary for this patient. The patient has several functional limitations as outlined by the UAS. Although the request was for additional hours due to declining status, the UAS did not demonstrate any significant decline. There are no clearly demonstrated functional needs that are not currently being tended to. The tasks that she requested assistance with (such as housework, meal preparation, and shopping) are accounted for under the tasking tool. The health plan has granted one more hour per day than is recommended by the task tool. Supervision was also requested, but this is not a stand-alone personal care function. There is no clearly demonstrated medical necessity for an increase in personal care hours at this time.

The health plan's determination of medical necessity is upheld in whole.