Diagnosis: Diabetes, hypertension, congestive heart failure and chronic obstructive pulmonary disease (COPD)

Treatment: Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 40 hours per week

The denial is modified

The patient has chronic medical problems including diabetes, hypertension, congestive heart failure and chronic obstructive pulmonary disease (COPD). She lives with her son in a 2-bedroom apartment. She was approved for CDPAS 14 hours/week. Under review is the requested increase Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's cognitive skills are described as "modified independent." She is fully alert and oriented. She "can describe emergency event and able to dial 911 in emergency event." The patient requires extensive assistance for bathing and lower body dressing. Otherwise, personal hygiene, upper body dressing and toilet transfer/use requires only limited assistance. She is continent of bowel and bladder. She is able to walk with a cane and contact guard assistance. The clinical records do not substantiate a level of physical/cognitive impairment, debility or significant functional decline to warrant the medical necessity of an increase in CDPAP hours to 40 per week. However, increasing CDPAP to 28 hours/week is clinically appropriate; allowing the patient to continue living safely at home.

The healthcare plan acted reasonably in part, with sound medical judgment and in the best interest of the patient. From a physical medicine and rehabilitation perspective, Consumer Directed Personal Assistance Services (CDPAS) 40 hours per week is not considered medically necessary. However, 28 hours per week is considered medically necessary.

The insurer's denial of coverage for consumer directed personal assistance services (CDPAS) 40 hours per week is modified. Medical Necessity for increasing CDPAP to 28 hours/week is substantiated.