Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple system atrophy, symptomatic
hypotension, gait instability, and neurogenic
bladder
Treatment: Increase in CDPAS from four days/week, nine hours/day to CDPAS four days/week, 11 hours/day, and 
Increase in PCW from three days/week, nine hours/day to PCW three days/week, 11 hours/day

The insurer denied the Increase in CDPAS from four days/week, nine hours/day to CDPAS four days/week, 11 hours/day, and 
Increase in PCW from three days/week, nine hours/day to PCW three days/week, 11 hours/day.

The denial is overturned.

This female has medical conditions including multiple system atrophy, symptomatic hypotension, gait instability, and neurogenic bladder.  She is appealing denial of increase in consumer directed personal assistance services (CDPAS) from four days/week, nine hours/day to consumer directed personal assistance services four days/week, 11 hours/day, and increase in personal care worker (PCW) from three days/week, nine hours/day to personal care worker (PCW) three days/week, 11 hours/day.  Uniform Assessment System (UAS) evaluation completed showed the patient transfers to the toilet with help, she utilizes a manual wheelchair for locomotion, and feeds herself.  

An appeal statement notes the patient's disease has progressed.  The patient cannot stand independently and is a fall risk.  It notes the patient is catheterized hourly for neurogenic bladder and needs assistance.  It states she is completely dependent for all activities of daily living (ADLs) and cannot be left alone.  An appeal letter from the patient's provider notes the patient is dependent on others for all of her needs.  Her condition has deteriorated since earlier in the  year and she is completely incapacitated.

Yes, the proposed treatment is medically necessary.
Personal Care 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 several chronic conditions including multiple system atrophy.  She is appealing denial of increase in consumer directed personal assistance services (CDPAS) from four days/week, nine hours/day to consumer directed personal assistance services (CDPAS) four days/week, 11 hours/day, and increase in personal care worker (PCW) from three days/week, nine hours/day to personal care worker (PCW) three days/week, 11 hours/day.  Uniform Assessment System (UAS) evaluation completed showed the patient transfers to the toilet with help, she utilizes a manual wheelchair for locomotion, and feeds herself.  Appeal letters note the patient's condition has deteriorated since earlier in the year and she is completely incapacitated. It states the patient is completely dependent for all activities of daily living (ADLs) and needs hourly assistance with bladder catherization.  The patient's condition is deteriorating.  The currently approved hours are insufficient to meet the increased needs, including hourly catheterization.  The proposed increase in consumer directed personal assistance services (CDPAS) from four days/week, nine hours/day to consumer directed personal assistance services (CDPAS) four days/week, 11 hours/day, and increase in personal care worker (PCW) from three days/week, nine hours/day to personal care worker (PCW) three days/week, 11 hours/day is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.