Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of stroke, osteoporosis
Treatment: Increase CDPAS (consumer directed personal assistance services) Hours from 53 Hours per Week To 81 Hours per Week
The insurer denied: Increase CDPAS Hours from 53 Hours per Week To 81 Hours per Week
The denial is overturned.

This patient is an elderly female with a history of general debility. The request was for consumer directed personal assistance services (CDPAS) to be increased from 53 hours per week based on Uniform Assessment System (UAS) of last year to 81 hours per week. The health plan denied the request because the patient has not shown significant change in ability to perform activities of daily living comparing the Uniform Assessment System of the two dates stated above, and requiring supervision to maximal assistance with activities of daily living and safety monitoring only authorized to be performed during the time assistance with activities of daily living is taking place. The additional hours requested are because of the patient's chronic medical conditions with unsteady gait making her homebound, bilateral hip pain in legs and knees, shortness of breath, and she is dependent on others for her activities of daily living including meal preparation, dressing, toilet transfer, bed mobility, i.e., most activities of daily living, etc. A review of the records showed that the patient has multiple chronic medical conditions including hypertension, a history of stroke, hypercholesterolemia, dizziness, vitamin D deficiency, hypothyroidism, asthma, brain aneurysm, coronary artery disease, anemia, herpes zoster, urinary incontinence, hypoglycemia, osteoporosis, varicose veins, COVID-19 infection, depression, cataracts, hernia, etc.
Uniform Assessment System-New York (UAS-NY) evaluation of 2 months ago showed that the patient required extensive assistance with mobility, walking, locomotion, transfer toilet, toilet use, and eating; required maximum assistance with upper/lower body dressing, bathing, etc.; and was totally dependent for meal preparation, medication management, and housework. Her family support is limited as she lives alone.

The requested health service is medically necessary.

The requested increase for consumer directed personal assistance services (CDPAS) from 53 hours per week based on Uniform Assessment System (UAS) of last year to 84 hours per week is medically necessary because based on the most recent Uniform Assessment System of 2 months ago, the patient is minimally cognitively impaired; requires supervision for bed mobility; limited assistance for phone use, personal hygiene, upper body dressing, eating; extensive assistance with managing finances, managing medications, bathing, walking, locomotion, toilet transfer; maximum assistance for meal preparation, stairs, shopping, transportation, lower body dressing, toilet use; and totally dependent for housework, etc. The reason for denial by the health plan as stated in the clinical information above does not align with the patient's disability features as stated in the Uniform Assessment System of 2 months ago as stated above. Therefore, the 81 hours per week based on Uniform Assessment System of 2 months ago as requested should be approved.