Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive decline, weakness.
Treatment: Consumer Directed Personal Assistance. A Total of 84 Hours Per Week
The insurer denied: Consumer Directed Personal Assistance. A Total of 84 Hours Per Week
The denial is overturned.

The member is an elderly female with a history of general debility with cognitive decline. The request was for Consumer Directed Personal Assistance to be increased from 70 hours per week (10 hours per day, 7 days per week) to 84 hours per week (12 hours per day, 7 days per week) based on UAS (Uniform Assessment System) of 6 months ago. The health plan denied the request because she has enough hours to support current ADLs (activities of daily living) including eating, bed mobility, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, toilet transfers, toilet use, etc. (and the rest). The 
previous time approved was enough to meet her current needs for ADLs (activities of daily living) and the clinical information does not support a need for any additional care hours. The additional hours requested are because of her chronic medical conditions including cognitive decline, and to help with her activities of daily living (ADLs) as she requires extensive assistance with dressing, meal preparation, showering, eating, shopping, bathing, toilet use, medication management, etc. (and the rest). A review of the records showed that the member has multiple chronic medical conditions including cognitive decline, hypertension, CAD (coronary artery disease), CHF, (congestive 
heart failure), dyspnea, history of falls, unsteady gait, anxiety, generalized osteoarthritis, etc. (and the rest). Uniform Assessment System-New York evaluation of 6 months ago showed that she was minimally cognitively impaired with supervision required at certain times, independent/supervision with eating, required limited assistance with bed mobility, extensive assistance with managing medications, phone use, transportation, bathing, personal hygiene, upper/lower body dressing, walking, locomotion, toilet transfer, toilet use, maximal assistance for meal preparation, housework, managing finances, stairs, shopping, etc. (and the rest). The member lives alone in a private home.

The requested increase for Consumer Directed Personal Assistance from 70 hours per week (10 hours per day, 7 days per week) to 84 hours per week (12 hours per day, 7 days per week) is medically necessary.

The requested increase for Consumer Directed Personal Assistance from 70 hours per week (10 hours per day, 7 days per week) to 84 hours per week (12 hours per day, 7 days per week) is medically necessary because based on the most recent UAS (Uniform Assessment System), personal care is medically necessary based on her extensive limitations and debility are good and tenable reasons for the medical necessity of increase hours of 6 months ago, in which she was minimally cognitively impaired with supervision required at certain times, 
independent/supervision with eating, required limited assistance with bed mobility, extensive assistance with managing medications, phone use, transportation, bathing, personal hygiene, upper/lower body dressing, walking, locomotion, toilet transfer, toilet use, maximal assistance for meal preparation, housework, managing finances, stairs, shopping, and the rest. 
The reason for denial by the health plan as stated in the clinical information above, does not align with her disability features as stated in the UAS (Uniform Assessment System), of 6 months ago as stated above. Therefore the 84 hours per week (12 hours per day, 7 days per week) based on UAS (Uniform Assessment System) of 6 months ago as requested should be approved.