Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abnormal gait, osteoarthritis, hypertension and dementia
Treatment: Increase Consumer Directed Personal Assistance Services From 7 Days Per Week 12 Hours Per Day To 7 Days Per Week 24 Hours Per Day, Live in
The insurer denied the Increase Consumer Directed Personal Assistance Services From 7 Days Per Week 12 Hours Per Day To 7 Days Per Week 24 Hours Per Day, Live in
The denial is upheld

The patient is a female. Her conditions include abnormal gait, osteoarthritis, hypertension and dementia.  Denial of increase in Consumer Directed Personal Assistance Services from 7 days per week 12 hours per day to 7 days per week 24 hours per day, live in, is being appealed.  The patient is able to ambulate 50 feet with a rollator and assistance.  She is able to transfer with minimal assistance.  She is able to feed herself.  She needs assistance with grooming, dressing, bathing, locomotion, toileting, and meal preparation.  She is current in a Rehab and Nursing facility. Upon discharge, the patient will be referred for skilled nursing and PT (physical therapy).  Shower chair, walker and hospital bed are planned upon discharge.

Statement from the caregiver notes the patient is received in wheelchair before bed.  The patient is intermittently agitated throughout the night.  She sometimes removes her diaper.  An appeal letter from the patient's provider notes that the patient is homebound and bedbound and needs additional hours for ADLs (activities of daily living).

No, 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. Denial of increase Consumer Directed Personal Assistance Services from 7 days per week 12 hours per day to 7 days per week 24 hours per day, live in, is being appealed.

This patient has several chronic medical conditions, including dementia.  She is currently in a rehab facility.  She requires assistance with transfers, grooming, dressing, bathing, locomotion, toileting, and meal preparation.  She is able to ambulate with a rollator and assistance.  Information provided for appeals shows the patient becomes agitated during nighttime and requires supervision.  The additional information provided does not show that the patient has nighttime needs for personal assistance services.  Personal assistance services are not indicated for supervision or when no services are being provided.  Evaluation will be performed at discharge to determine the patient's needs for skilled care.  Based on the patient's current functioning, the approved CDPAS (consumer directed personal assistance services) 12 hours per day to 7 days per week is appropriate and medically necessary to meets the patient's needs for assistance with ADLs (activities of daily living) and personal care.  The requesed increase to CDPAS (consumer directed personal assistance services) 7 days per week 24 hours per day, live in is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.