Diagnosis: Severe bilateral eye macular degeneration and associated legal blindness, human immunodeficiency virus (HIV) and asthma.
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) from 28 Hours to 63 Hours per Week.
The insurer denied the Increase Consumer Directed Personal Assistance Services (CDPAS) from 28 Hours to 63 Hours per Week.
The denial is overturned.

The patient is a female with a history of severe bilateral eye macular degeneration and associated legal blindness, human immunodeficiency virus (HIV) and asthma. 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 63 hours per week Personal Assistance Services to offer increased activities of daily living support.

Yes, the proposed treatment of 63 hours per week Personal Assistance Services is deemed medically necessary.

An assessment of the patient's functionality and ability to perform activities of daily living was completed and determined that the currently approved plan of 28 hours per week Personal Assistance Services is sufficient to meet the patient's current needs.

However, recent correspondence from the patient's medical providers indicates that due to progressively worsening visual acuity, the patient is now legally blind in her right eye and almost completely blind in her left eye. In addition, her physician reports that her vision loss is permanent with no hope for recovery. Hence, she is unable to ambulate or perform her activities of daily living without assistance. For these reasons, the proposed treatment of 63 hours per week Personal Assistance Services is deemed medically necessary.