Diagnosis: History of Alzheimer's Disease, Coronary Heart Disease and End Stage Osteoarthritis of Bilateral Knees.
Treatment: CDPAS 80 hours per week
The insurer denied the CDPAS 80 hours per week.
The denial is overturned.

The patient is a female with a history of Alzheimer's Disease, Coronary Heart Disease and End Stage Osteoarthritis of Bilateral Knees. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of an increase in Personal Assistance Services to 80 hours/week to offer increased ADL support.

Yes, the proposed treatment of an increase in Personal Assistance Services to 80 hours/week is deemed medically necessary.

Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's physician indicates that the patient has demonstrated progressive functional decline with worsening bilateral knee pain and decreased range of motion secondary to worsening osteoarthritis and worsening lower extremity edema. For these reasons, her gait ataxia has worsened and the currently approved plan of 40 hours/week Personal Assistance Services is no longer sufficient to meet the patient's current needs. For these reasons, the proposed treatment of an increase in Personal Assistance Services to 80 hours/week is deemed medically necessary.