Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unsteady gait, forgetful

Treatment: consumer directed personal assistance services (CDPAS) 24 hours a day (live in), 7 days a week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 24 hours a day (live in), 7 days a week.

The denial is upheld.


 
This case involves an adult male seeking coverage of 24 hours/day 7days/week (live-in) consumer directed personal assistance services (CDPAS).

The Uniform Assessment System comprehensive medical assessment indicates the patient is alert and oriented x2, with a history of alcohol (ETOH) abuse. The patient was able to answer questions with some repetition. The patient usually understands and understood others. The patient can self-direct care.  The patient requires maximal assistance to extensive assistance with his instrumental activities of daily living (IADLs) such as meal preparation, housework, medication management, shopping, and transportation.  The patient requires extensive assistance with weightbearing support in bathing, upper body dressing, lower body dressing, walking, locomotion, toilet transfer, toileting, and bed mobility.  He requires limited assistance with upper body dressing and personal hygiene.  The patient does not drive. The plan provides benefits for transportation.  The patient reported that he has a slow and unsteady gait.  The patient's daughter manages meal preparation, shopping, housekeeping, finances, and medication.  The patient uses a walker. He reports 4 falls in the last month without injury. It happened while he attempted to transfer up or down stairs while not using assistive device and daughter witnessed the falls. No reported hospitalizations or emergency room (ER) visits in the last 90 days. Increase in Nursing Facility Level of Care (NFLOC) score by 15 due to declining mobility and worsening alcoholism.


The information gathered in the most recent assessment done on 08/03/2023 and other medical records submitted for review do not support the level of care requested. The records indicate the patient needs help with meal preparation, housekeeping, laundry, shopping, dressing, bathing, hygiene, and bathing.  The patient lives with his daughter who directs care and makes important decisions for the patient. The record indicates that the patient has unsteady gait and moves around in his environment using a walker.  He is sometimes forgetful, but he is alert and able to make his needs known. There is no reported history of wandering and elopement. The plan recommends physical therapy for strengthening and endurance. Physical therapy will also help and direct on how to transfer and how to utilize durable medical equipment (DME) to prevent falls.  Based on the assessment and evaluation tools, the patient was approved for 39.5 hours/week of personal assistance services. The plan can also provide a personal emergency response system (PERS) that the patient can use to call for help with a push button. The records provided did not indicate that the patient has a medical condition that warrants continuous supervision/assistance. The patient requires some assistance and is not completely dependent on activities of daily living (ADLs) or IADLs. There hasn't been a noticeable decrease in the ability to perform or evidence of a need to qualify for the continuous assistance services. The assessment does support the determination of partial approval of personal care services for 39.5 hours/week that can be used flexibly to meet the patient's needs. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for consumer directed personal assistance services (CDPAS) 24 hours a day (live in), 7 days a week is not substantiated.