Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced Alzheimer's disease, tremors, neuropathy, coronary after disease, atrial fibrillation, and osteoarthritis arthritis. 
Treatment: Increase Personal Care Aide (CDPAS) to 56 Hours per Week. 

The insurer denied: Increase Personal Care Aide (CDPAS) to 56 Hours per Week. 
The denial is overturned. 

This elderly male has conditions including advanced Alzheimer's disease, tremors, neuropathy, coronary after disease, atrial fibrillation, and osteoarthritis arthritis. He lives alone. 

He is appealing denial of increase personal care aide (CDPAS) to 56 hours per week. The health plan approved consumer directed personal assistant services (CDPAS) to 42 hours per week. 

Uniform Assessment System (UAS) evaluation performed recently shows the patient has minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, stairs, and shopping; extensive assistance with managing finances, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting; and limited assistance with bed mobility and eating. The patient has bladder incontinence. A statement from the health care proxy notes the patient is homebound and unable to perform activities of daily living (ADLs) without assistance. 

A progress report from his Provider notes the patient has progressive cognitive impairment, weakness, numbness, and tremors. He requires assistance with all activities of daily living (ADLs). The patient has day and night confusion. A letter from another of his Providers notes the patient is homebound and requires assistance with activities of daily living (ADLs). He has generalized weakness. He ambulates with a walker and contact guard assistance. He requires assistance with all transfers. A letter from a third Provider notes the patient has memory impairment, limited ambulation and is a high fall risk. The patient's cognitive function has decreased. 

The proposed treatment is medically necessary. 

Personal Assistance 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 multiple chronic conditions. He is appealing the denial of an increase in personal care aide (CDPAS) to 56 hours per week. The health plan approved consumer directed personal care assistant services (CDPAS) to 42 hours per week. Uniform Assessment System (UAS) evaluation performed recently shows the patient needs assistance with all activities of daily living (ADLs). Appeal statements support the patient is homebound and needs assistance with all activities of daily living (ADLs). These statements indicate the patient's cognitive and physical impairments have declined. This patient's physical functioning is significantly impaired. The need for assistance with all activities of daily living (ADLs) cannot be met with the approved consumer directed personal assistant services (CDPAS) to 42 hours per week. The proposed increase in consumer directed personal assistant services (CDPAS) to 56 hours per week is medically necessary and appropriate.