Diagnosis: Hypertension, osteoporosis, lung cancer status post left upper lobectomy, dementia and gait ataxia.
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) from 7 Days per Week, 8 Hours per Day; 56 Hours per Week to Consumer Directed Personal Assistance Services 7 Days per Week, 24 Hours per Day, Continuous, Split Shift, by More than One Person; 168 Hours per Week.

The insurer denied the Increase Consumer Directed Personal Assistance Services (CDPAS) from 7 Days per Week, 8 Hours per Day; 56 Hours per Week to Consumer Directed Personal Assistance Services 7 Days per Week, 24 Hours per Day, Continuous, Split Shift, by More than One Person; 168 Hours per Week. The denial is overturned.

The patient is a female with a history of hypertension, osteoporosis, lung cancer status post left upper lobectomy, dementia and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 168 hours per week Personal Assistance Services to offer increased activities of daily living (ADL) support.

Yes, the proposed treatment of 168 hours per week Personal Assistance Services is deemed medically necessary.

An assessment of the patient's functionality was performed and revealed that that patient is totally dependent on assistance from others for completion of meal preparation, housework, managing finances, medications, phone use, stairs, shopping, transportation, toilet transfers, toilet use and dressing. In addition, recent correspondence from the patient's medical provider indicates that due to the patient's history of severe Alzheimer's dementia, she is dependent on others for assistance with all activities of daily living.

For these reasons, the currently approved plan of 63 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. Also for these reasons, the proposed treatment 168 hours per week Personal Assistance Services is deemed medically necessary.