Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, carpal tunnel syndrome, weakness, and arthritis
Treatment: Increase Consumer Direct Personal Assistance Program (CDPAP) Services for a Total Amount of 40 Hours per Week
The insurer denied: Increase Consumer Direct Personal Assistance Program (CDPAP) Services for a Total Amount of 40 Hours per Week
The denial is upheld.

The patient is an adult female that has medical conditions that include dementia, carpal tunnel syndrome, weakness, and arthritis. She lives with her husband in a three-bedroom apartment. The denial of an increase in consumer direct personal assistance program (CDPAP) services for a total amount of 40 hours per week is being appealed. The health plan approved a total of 22.5 hours per week. The Uniform Assessment System (UAS) evaluation completed a few months ago shows minimally impaired cognition and functional status requires assistance with all activities of daily living (ADLs), except phone use and eating. She has bowel and bladder incontinence. The patient's daughter is involved in care. Compared to Uniform Assessment System evaluation completed a few years ago, there has been a decline with upper body dressing, personal hygiene, toilet use, and bed mobility. A letter from the Provider notes the patient's cognitive impairment has progressed. The patient is unable to understand how to perform tasks. She does not remember names of relatives. Her family monitors her by remote camera. A letter from the patient's daughter notes the patient has vascular dementia and is unable to perform simple tasks. She requires supervision.

The requested health service is not 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. The denial of an increase in consumer direct personal assistance program (CDPAP) services for a total amount of 40 hours per week is being appealed. The health plan approved a total of 22.5 hours per week. The patient's daughter assists with care. Uniform Assessment System (UAS) evaluation completed a few months ago shows the patient requires assistance with all activities of daily living, except phone use and eating. The patient has bowel and bladder incontinence. Compared to Uniform Assessment System 
evaluation completed a few years ago, there has been a decline with upper body dressing, personal hygiene, toilet use, and bed mobility. Appeal letters report the patient's cognitive impairment has progressed. The patient is unable to perform simple tasks and needs supervision. The information provided does not support that the patient has functional needs requiring an increase in consumer direct personal assistance program hours. Consumer direct personal assistance program is not indicated for safety supervision. The approved consumer direct personal assistance program 22.5 hours per weeks is sufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 40 hours per week is not medically indicated.