Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 diabetes with diabetes foot ulcer with
gangrene, status post toe and heel amputation.
Treatment:  Increase Consumer Directed Personal Assistance (CDPAS) From 35 Hours Per Week to 7 Days per Week, 24 Hours Per Day, Live in. 91 Hours Per Week (The health plan approved increase to 49 hours/week)
The insurer denied the  Increase Consumer Directed Personal Assistance (CDPAS) From 35 Hours Per Week to 7 Days per	Week, 24 Hours Per Day, Live in. 91 Hours Per Week (The health plan approved increase to 49 hours/week)
The denial is overturned.

This female has conditions including impaired mobility, lower extremity lymphedema, chronic DVT (deep vein thrombosis), morbid obesity, osteoarthritis, lumbar radiculopathy, type 2 diabetes with diabetes foot ulcer with gangrene, status post toe and heel amputation. She is appealing denial of increase consumer directed personal assistance (CDPAS) from 35 hours per week to 7 days per week, 24 hours per day, live in, 91 hours per week. The health plan approved an increase to 49 hours per week. Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with meal preparation and housework; maximal assistance with bathing, lower body dressing, and toilet transfer; extensive assistance with managing medications, personal hygiene, and upper body dressing; and limited assistance with managing finances, bed mobility and eating. The member is bed bound. She has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation previously, there has been a decline in functioning with meal preparation, housework, lower body dressing, and locomotion. A letter from the provider notes the member has chronic pain and is nonambulatory. 

An appeal statement from New York State notes the member has multiple chronic conditions and is bedbound. Her son has been providing both formal and informal care, but no longer able to provide informal care. She is totally dependent with all ADLs (activities of daily livings). 

Physician's order note that the member is bed bound and needs assistance with toileting, transferring, turning and positioning during the day that would not allow for an aide to get five hours of uninterrupted sleep. 
The member and her son have provided statements indicating necessity for more hours. Logs show the member is receiving continuous care.

No. The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding.  This member has multiple chronic medical conditions and is bed bound.  She is appealing denial of increase CDPAS from 35 hours per week to 7 days per week, 24 hours per day, live in, 91 hours per week.  The health plan approved an increase to 49 hours per week.  Uniform Assessment System (UAS) evaluation completed shows she requires assistance with all ADLs (activities of daily livings).  Compared to UAS (Uniform Assessment System) evaluation previously, there has been a decline in functioning with meal preparation, housework, lower body dressing, and locomotion.  She has bowel and bladder incontinence.  Appels statements note the member is bed bound and totally dependent.  She is no longer able to depend on informal support of her son.  Her provider notes that she needs assistance with ADLs (activities of daily livings) as well as turning and positioning. Logs show the member is receiving continuous care.  The member has significant limitations that requires assistance with all ADLs (activities of daily livings) that cannot be met with the approved CDPAS (consumer directed personal assistance) 49 hours per week. The proposed CDPAS (consumer directed personal assistance)7 days per week, 24 hours per day, live in, 91 hours per week is medically necessary to meet the member's needs for assistance with ADLs (activities of daily livings) and personal care.