Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal, Left AKA.
Treatment: Consumer Directed Personal Assistance Services.
The insurer denied Consumer Directed Personal Assistance Services (CDPAS), 24-Hour Continuous Care, 7 Days per Week. The health plan's determination is overturned in part. 10 hours a day 7 days week for a total of 70 hours a week is indicated for this patient.

The patient is a female with a medical history significant for left above knee amputation (AKA), peripheral artery disease, chronic obstructive pulmonary disease (COPD), congestive for failure, coronary artery disease and chronic bronchitis.
She is currently authorized to receive 56 hours a week 8 hours a day 7 days a week. She is requesting an increase in personal care hours to 168 hours a week, 24 hours a day 7 days a week. The plan approved 56 hours a week, 8 hours a day 7 days a week.

10 hours a day 7 days week for a total of 70 hours a week is indicated for this patient.
The patient is a female with multiple medical problems. She was admitted to the hospital in earlier in the year with peripheral vascular disease resulting in a left above the knee amputation. She completed follow-up rehabilitation in skilled care and was subsequently discharged home. She was encouraged to stay in the skilled unit until her wounds were healed.
Based on the rehab notes, it was noted that the patient has not reached rehab potential and is not recommended for rehab at this time and was discharged home at her request.
The patient is alert and oriented to person place and time. She was approved for 56 hours a week of CD (consumer directed) PAS (personal assistant services) for hands-on care needs including meal preparation, housekeeping, shopping, bathing, personal hygiene, dressing, toileting transfers, and medical appointments. These hours can be spread it to 4 hours in the morning and 4 hours in the evening. The additional hours would be for supervision as a stand-alone and is not something that is indicated.
Task tool notes the patient requires total 42 hours a week of personal care services. Task tool notes the patient requires a total of 56 hours a week of personal care services.
The most recent Uniform Assessment System (UAS) and tasking tool noted the patient required a total of 56 hours a week, 8 hours a day 7 days a week for activities of daily living (ADL) and Instrumental activities of daily living (IADL). Since the patient had a recent AKA and is having more difficulty with transfers, it is reasonable for additional hours. 10 hours a day 7 days week for a total of 70 hours a week is indicated for this patient. These services can be split according to the patient's needs. 10 hours a day are sufficient to meet her medical needs. There was no documented need in specific which would necessitate continuous care. It was noted that the patient had a recent AKA and required wound care. She does have visiting nurses along with physical therapy (PT) and occupational therapy (OT) in regards for follow-up. There is no medical necessity noted that would require frequent turning or repositioning in the middle the night. There were no other services noted that would require nocturnal services that cannot be addressed during 10 hours a day of services.