Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, polyneuropathy, myalgia fatigue, generalized osteoarthritis, lumbar radiculopathy, depression, hyperlipidemia, and history of falls. 
Treatment: Increase Consumer Directed Personal Assistance (CDPAS) to 7 Days per Week 8 Hours per Day for a Total of 56 Hours per Week. 
The insurer denied: Increase Consumer Directed Personal Assistance (CDPAS) to 7 Days per Week 8 Hours per Day for a Total of 56 Hours per Week. 
The denial is overturned. 

The patient is an elderly female with a history of general debility. The request was for Consumer Directed Personal Assistance (CDPAS) to be increased from 31.5 hours per week (4.5 hours per day, 7 days per week) based on Uniform Assessment System (UAS) of 7 months ago to 56 hours per week (8 hours per day, 7 days per week) based on Uniform Assessment System of 3 months ago. The health plan denied the request because the patient has a supporting son who can direct her care; is alert and oriented to person, place, and time with some forgetfulness; is able to make her needs known; and is able to express an emergency plan, etc. In addition, the current activities of daily living (ADL) needs are sufficiently infrequent and can be safely and adequately met through the approved 31.5 hours per week. 
The additional hours requested are because of the patient's rapidly deteriorating mental, physical, and functional state with cognitive decline due to chronic medical conditions, and to help with her activities of daily living as she requires extensive assistance with dressing, bathing, grooming, transferring, turning, positioning, toileting, ambulation, meal preparation, eating, housekeeping, and shopping., etc. A review of the records showed that the patient has multiple chronic medical conditions including hypertension, polyneuropathy, myalgia fatigue, generalized osteoarthritis, lumbar radiculopathy, depression, hyperlipidemia, and history of falls. Uniform Assessment System-New York (UAS-NY) evaluation of 3 months ago showed that the patient was cognitively intact, forgetful at times, and independent with making decisions, but required limited assistance with managing medications, phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, bed mobility, eating, required extensive assistance with managing finances, stairs, transportation, bathing, toilet use, and required maximal assistance for meal preparation, housework, shopping, lower body dressing, etc. The patient lives alone in a two-bedroom private home with five steps to enter and with her granddaughter visiting. 

The requested health service is medically necessary. 

The requested increase for Consumer Directed Personal Assistance (CDPAS) to be increased from 31.5 hours per week (4.5 hours per day, 7 days per week) to 56 hours per week (8 hours per day, 7 days per week) is medically necessary based on the patient's long list of medical conditions. In addition, the patient was cognitively intact, forgetful at times and independent with making decisions, but required limited assistance with managing medications, phone use, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, bed mobility, eating; required extensive assistance with managing finances, stairs, transportation, bathing, toilet use; and required maximal assistance for meal preparation, housework, shopping, and lower body dressing. She lives alone in a two-bedroom private home with five steps to enter and with her granddaughter visiting. 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 3 months ago. Therefore the 56 hours per week (8 hours per day, 7 days per week) as requested should be approved. The requested health service is medically necessary.