Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizophrenia and obsessive compulsive disorder.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) to 84 Hours Per Week.
The insurer denied: Consumer Directed Personal Assistance Services (CDPAS) to 84 Hours Per Week.
The denial is upheld.

This adult female has schizophrenia and obsessive-compulsive disorder. This is an appeal for the denial of consumer-directed personal assistance services (CDPAS) for 84 hours per week. The health plan approved 49 hours per week. Uniform Assessment System (UAS) evaluation shows moderately impaired cognition and functional status: total dependence on meal preparation, housework, managing finances, and shopping; extensive assistance with managing medications, transportation, and bathing; limited assistance with personal hygiene and dressing; independent with walking, locomotion, toilet transfer, and bed mobility; and supervision with toilet use and eating. She has occasional urinary incontinence.  
A letter from the patient's sister states the patient requires full-day supervision including assistance with personal care and activities of daily living (ADLs). A submitted letter notes the patient is on regular psychiatric treatment. She has a current diagnosis of disorganized schizophrenia resulting in functional limitations. She is not able to function independently, she is selectively mute, and cannot travel or be left without supervision.

The proposed treatment, consumer-directed personal assistance services (CDPAS) for 84 hours per week, is not medically necessary.
Personal assistance services provide hands-on assistance to individuals including assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has disorganized schizophrenia. This is an appeal for the denial of consumer-directed personal assistance services (CDPAS) for 84 hours per week. The health plan denied the increase because hours are not indicated for safety supervision separate from personal care tasks. Safety supervision is not provided as a stand-alone function. The health plan approved 49 hours per week. Uniform Assessment System (UAS) evaluation shows the patient is independent with walking, locomotion, toilet transfer, and bed mobility; and supervision with toilet use and eating. She requires assistance with meal preparation, housework, managing finances, shopping, managing medications, transportation, bathing, personal hygiene, and dressing. The appeal statements indicate the patient needs daily supervision and cannot be left alone. The information provided does not support that the patient has functional needs requiring consumer-directed personal assistance services (CDPAS) for 84 hours per week. Consumer-directed personal assistance services (CDPAS) for 84 hours per week are not indicated for supervision or when no tasks are being performed. The approved consumer-directed personal assistance services (CDPAS) of 49 hours per week is sufficient to meet this patient's needs for assistance with activities of daily living (ADLs). Therefore, the proposed consumer-directed personal assistance services (CDPAS) 84 hours per week is not medically necessary.