Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 7 days per week 8 hours per day from 11pm to 9am, and 4 days per week, 4 hours per day (Monday, Thursday, Saturday and Sunday); during the day time; 72 hours per week.
The insurer denied Consumer Directed Personal Assistance Services (CDPAS) 7 days per week 8 hours per day from 11pm to 9am, and 4 days per week, 4 hours per day (Monday, Thursday, Saturday and Sunday); during the day time; 72 hours per week.
The health plan's determination is upheld. 

The patient is a male with a medical history of atrial fibrillation, unsteady gait, early dementia, decreased vision and frequent urination. The patient is approved for 4 hours per day, 4 days per week (16 hours per week) of Consumer Directed Personal Assistance Services (CDPAS). 

A letter of support for this appeal was provided by the patient's physician stating that the patient has an unsteady gait and is working with physical therapy. He is followed by urology for benign prostatic hyperplasia but continues to urinate four times per night despite treatment. He had a fall this year while ambulating at night. For this reason, the physician requested increased personal care hours for the patient at night.
A letter of support for this appeal was provided by the patient's ophthalmologist. The letter states that he is being treated for optic neuropathy. The physician recommends optimal control of his hypertension. There is no discussion of personal care needs.

A letter of support for this appeal was provided from the patient's neurologist. The letter states that he has a history of falls due to gait difficulties and that he was wheelchair bound at the time of the letter. The letter states that he has dementia without behavioral disturbance and has had difficulty with sleeping. The physician feels that he would "benefit from additional home care hours for his safety, and for activities of daily living." A mini-mental status examination was performed and the patient scored 26 out of 30.
The patient was discharged from physical therapy. The physical therapy discharge summary notes that he has made slight positive gains in exercise endurance and tolerance but continues to have significant deficits with endurance and weightbearing activity.

A Uniform Assessment System (UAS) that was recently completed was available for review. The patient's cognition was minimally impaired. From a functional standpoint, he requires total dependence for housework and shopping. He requires maximal assistance with managing finances and medications. He requires extensive assistance for stairs and transportation. For his activities of daily living (ADL's), he requires extensive assistance for bathing and toilet transfers. All other ADL's require limited assistance (hygiene, dressing, walking, locomotion, toilet use, bed mobility and eating). He is occasionally incontinent of urine and infrequently incontinent of stool. Compared with a prior UAS, the patient's functional status remained essentially unchanged. A tasking tool associated with the most recent assessment recommended 2.4 hours per day, 4 days per week (total of 16.9 hours per week) to address his functional needs. This was the total after applying deductions for time in adult daycare and CDPAS hours received by his wife for the same household tasks. This reduction did not reduce hours for his night needs due to assistive devices.

The patient's functional status as reflected by the UAS has remained unchanged from last year to this year. The notes reflect that he has been having worsening dementia with night time disturbances. It is not clear if there is a functional need for personal care in the night time hours given that his functional capacity has not changed. If the need for increased personal care is due to his dementia, that would not prove medical necessity for increased CDPAS hours.