Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertension, coronary artery disease, neuropathy, thoracic compression fracture, osteoarthritis, memory impairment, and vertigo.
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP) to 56 Hours per Week.
The insurer denied: Increase Consumer Directed Personal Assistance Program (CDPAP) to 56 Hours per Week.
The denial is overturned.

This patient is an elderly female has conditions including hypertension, coronary artery disease, neuropathy, thoracic compression fracture, osteoarthritis, memory impairment, and 
vertigo. She lives alone. She is appealing the denial of an increase in consumer directed personal assistance program (CDPAP) in the amount of 56 hours per week. The health plan approved: consumer directed personal assistance program for six hours per day, seven days per week, for a total of 42 hours per week. Uniform Assessment System evaluation completed 8 months ago shows the patient has modified independent cognition and functional status: total dependence with housework and shopping; maximal assistance with meal preparation, managing finances and medications, dressing, toilet use, personal hygiene, and bathing; and extensive assistance with toilet transfer, walking, locomotion, bed mobility, and eating. She had a decline in activities of daily living due to a recent spine fracture and progression of osteoarthritis. She has bowel and bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation completed on the prior year, there has been a decline with managing finances and medications, shopping, 
personal hygiene, upper body dressing, and toilet use. A letter from her Provider lists the patient's chronic conditions. The letter notes the patient has difficulty walking, dizziness, and 
weakness. She is not safe to be left alone. She is forgetful and needs constant reminding and supervision. She needs assistance with activities of daily living. A letter from another Provider notes the patient has exertional dyspnea, weakness, and fatigue. She has impaired memory. She has limited mobility due to back pain. She requires reminders and supervision for medications. She requires extensive assistance with activities of daily living. She is status post a recent fall with a left arm hairline fracture. A letter from New York State notes the patient's needs for assistance with activities of daily living as already outline in the Uniform Assessment System (UAS) evaluation.

The proposed treatment is 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. She is appealing the denial of an increase in consumer directed personal assistance program (CDPAP) in the amount of 56 hours per week. The health plan approved: consumer directed personal assistance program for six hours per day, seven days per week, for a total of 42 hours per week. Uniform Assessment System Evaluation completed 8 months ago shows the patient requires assistance with all activities of daily living. Compared to Uniform Assessment System evaluation completed the year prior, there has been a decline with managing finances and medications, shopping, personal hygiene, upper body dressing, and toilet use. The patient has bowel and bladder incontinence. Appeal statements support a decline in the patient's functioning and need for frequent cuing. There is no evidence of informal support. The information provided show that the patient has significant limitations in functioning that have declined between Uniform Assessment System evaluations. The approved consumer directed personal assistance program 42 hours per week is insufficient to meet the patient's needs for assistance with activities of daily living. The proposed increase in consumer directed personal assistance program to 56 hours per week is medically necessary.