Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Insulin-dependent diabetes mellitus (IDDM),
coronary artery disease (CAD), osteoarthritis
(OA), obesity, and atrial (A) fibrillation.
Treatment: Increase Consumer Directed Personal Assistance Services to 49 Hours per Week, Pre-service.
The insurer denied the Increase Consumer Directed Personal Assistance Services to 49 Hours per Week, Pre-service.
The denial is overturned.

This patient is a male with conditions including insulin-dependent diabetes mellitus (IDDM), coronary artery disease (CAD), osteoarthritis (OA), obesity, and atrial (A) fibrillation.  The patient is reported to have cognitive and physical decline.  This is an appeal for denial of consumer directed personal assistance services (CDPAS) at 49 hours per week.  He has been approved for 21 hours per week.  He lives alone in a one bedroom.  

Uniform Assessment System (UAS) evaluation performed shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances, stairs, and bathing; limited assistance with managing medications, phone use, lower body dressing, and toilet use; supervision with walking, locomotion, and toilet transfer; and independent with personal hygiene, upper body dressing, bed mobility, and eating.  The patient ambulates using nearby furniture or walls. The patient has durable medical equipment (DME) including grab bar, personal emergency response system (PERS), diabetic supplies, chucks, and male pads.  He has been recommended for cane, urinal and shower chair.  He is occasionally incontinent of bladder. 

A letter from the patient's provider states the patient needs help all day with tasks due to incontinence, memory problems, functional limitation and weakness.  It states the patient is newly incontinent.  It notes the patient needs assistance with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation.  It is recommending an increase in personal care service (PCS) to 49 hours per week.  

Geriatric/Palliative progress note shows deterioration in functional status. The patient was independent with activities of daily living (ADLs) and now requires assistance with dressing, grooming, and bathing.  He requires reminders to eat.  The patient was newly incontinent and now incontinent less than once weekly.  Other than phone use, he is now unable to perform instrumental activities of daily living (IADLs).

The proposed increase in consumer directed personal assistance services to 49 hours per week is medically necessary.
Medically necessary services are those which are:
safe 
effective
generally accepted national standard of medical practice 
not provided primarily for convenience of the patient or the practitioner 
the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The proposed treatment is medically necessary because it is consistent with generally accepted national standard of medical practice.

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 is appealing the denial of 49 consumer directed personal assistance services (CDPAS) hours per week.  Consumer directed personal assistance services (CDPAS) hours were increased from 12 to 21 hours per week.  In addition, the patient was given assistive devices of grab bar, personal emergency response system (PERS), chucks, and diabetic supplies.  Uniform Assessment System (UAS) evaluation performed shows the patient can perform the following without assistance: walk, toilet transfer; personal hygiene, upper body dressing, bed mobility, and eat.  The letter and clinical records show a decline in the patient's functioning to where he is now unable to perform instrumental activities of daily living (IADLs) with exception of phone use.  He is newly incontinent since the Uniform Assessment System (UAS) evaluation.  He requires reminders to eat.  Other than eating, the patient requires assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs).  The patient has declined in his functioning.  The patient's level of functioning, incontinence and cueing for eating require more than the approved personal assistance services (PAS) 21 hours per week.  The requested 49 personal assistance service (PCS) hours per week are medically necessary.