Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other- hemiplegia 
Treatment: Consumer Directed Personal Assistance, a total of 40 hours per week
The health plan denied: Consumer Directed Personal Assistance, a total of 40 hours per week.
The determination is Overturned.

The patient is a female with a medical history notable for prior cerebral infarction, hemiplegia, hemiparesis, hypertension, vascular dementia, and urinary incontinence. The patient is approved for 27 hours per week of consumer directed personal assistance. The patient and her care team requested an increase to 40 hours per week, and this request was denied by the health plan.
The patient's physician provided a letter of support for this appeal. The letter details the patient's multiple medical problems, including prior subarachnoid hemorrhage affecting the dominant side with resulting neurologic deficits. The physician states that the patient is dependent on others to complete activities of daily living. She requires prompting assistance for morning and evening routines due to her cognitive and functional impairments. She also requires assistance with walking due to an unsteady gait. Therefore, the physician attests that the increase in personal care services is medically necessary for the patient.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient was alert and oriented. She is self-directing and can make decisions regarding daily activities but is very forgetful and has a diagnosis of early stage dementia. For her instrumental activities of daily living, the patient requires maximal assistance with meal preparation, housework, finances, and shopping. She requires extensive assistance for medications, stairs, and transportation. For her activities of daily living, she requires extensive assistance for bathing, hygiene, dressing her lower body, and toilet transfer. She requires limited assistance for dressing her upper body, walking, locomotion, and toilet use. She is continent of stool, but frequently incontinent of urine, requiring the use of diapers for incontinence care. A task tool associated with the assessment recommended 26.7 hours per week to address her personal care needs. Compared with a prior assessment, the patient had a decline in functional status across multiple domains.
At issue is the medical necessity of Consumer Directed Personal Assistance, a total of 40 hours per week.
The health plan's determination of medical necessity is overturned in whole.
The requested health service of Consumer Directed Personal Assistance, a total of 40 hours per week, is medically necessary for this patient.
The patient was awarded 27 hours per week which was recommended by the task tool. The task tool serves as a useful starting place for determining personal care hours, but cannot be relied on as the final determining factor in the number of hours that a patient requires each week. Given the patient's cognitive and functional deficits from her prior cerebral infarction and hemorrhage, it is reasonable to expect that she may require more than 27 hours per week. The requested increase from 27 to 40 hours per week is medically necessary as attested by the patient's physician and reasonable given her assessments. She likely requires frequent and unscheduled assistance with activities of daily living tasks and other tasks such as incontinence care.