Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CHF (congestive heart failure), diabetes mellitus, dizziness, unsteady gait, general weakness, and history of multiple falls, severe impaired mobility, and cognitive impairment
Treatment: Increase Consumer Directed Personal Assistance 
(CDPAP) For a Total of 40 Hours Per Week
The insurer denied: Increase Consumer Directed Personal Assistance (CDPAP) For a Total of 40 Hours Per Week
The denial is overturned.

This patient is an elderly female with history of general debility. This request is for Personal Care Assistance through Home Health care (Level 2 [two]), to be increased from 20 hours per week (4 (four) hours per day 5 (five) days a week) to 40 hours per week (8 (eight) hours per day, 5 (five) days a week). The request for an increase in the number of hours per week is based on the patient's need for more assistance, as she reportedly has an increased amount of clinical appointments, and requires more assistance with laundry, cleaning, grooming, cooking, etc. The health plan denied the request based upon the patient's ability to perform physical functioning with self-directing, which is considered adequate, as she is also able to walk with the assistance of a cane and has the ability to perform personal hygiene after needed items are placed within reach. The time previously allotted for personal care assistance was for meal preparation, light housekeeping, and transportation (including transport to and from medical appointments). The patient has been advised to adjust her approved 4 (four) hours per day, 5 (five) days per week, to be used for her medical appointments. 
A review of the records showed that patient has multiple medical conditions including CHF (congestive heart failure), diabetes mellitus, dizziness, unsteady gait, general weakness, and history of multiple falls, associated with limited range of motion, severe impaired mobility, ambulating with walker with one person assist, and cognitive impairment, all likely to place her at serious risk of injury, hence why the patient reportedly "needs assistance around the clock." An UAS-NY (Uniform Assessment System for New York) evaluation 4 months ago showed that the patient was minimally impaired, required extensive assistance with toilet use, toilet transfer, walking, locomotion, bed mobility, lower body dressing, and she required supervision with eating. She is also incontinent of bladder and bowel. The client task sheet for PCA (Personal Care Assistance) level 2 (two) was calculated to require 42 hours per week. The request for increased hours is under review. 

The requested health service of an Increase Consumer Directed Personal Assistance (CDPAP) For a Total of 40 Hours per Week, is considered medically necessary. 

The requested increase for Personal Care Assistance through Home Health care (Level 2) from 20 hours per week (4 hours per day 5 days a week) to 40 hours per week (8 hours per day, 5 days a week) is considered medically necessary, based on this patient's most recent UAS performed 4 months ago, in which she was found to be minimally impaired, and she required extensive assistance with toilet use, toilet transfer, walking, locomotion, bed mobility, lower body dressing, and supervision with eating. She is also incontinent of bladder and bowel. The client task sheet for PCA level 2 was calculated to require 42 hours per week. Therefore, the requested 40 hours per week (8 hours per day, 5 days a week) should be approved, as it is considered medically necessary for this patient.