Diagnosis: Multiple sclerosis
Treatment: Increase Consumer and Self Directed Personal Assistance Service (CDPAS) to 40 Hours Per Week
The insurer denied the Increase Consumer and Self Directed Personal Assistance Service (CDPAS) to 40 Hours Per Week
The denial is upheld

The patient is a female with multiple sclerosis (MS) and concomitant gait impairment. She uses a walker to ambulate. The provider is requesting increased Consumer and Self Directed Personal Assistance Service (CDPAS) from 32 hours per week to 40 hours per week.

No, the requested Increase Consumer and Self Directed Personal Assistance Service (CDPAS) to 40 Hours Per Week is not medically necessary.
The patient is able to ambulate with a walker and transfer independently. There is no documented reason her needs cannot be met with the provided 32 hours per week. There is no significant change in her condition to support additional hours.

Therefore, the requested increase in service hours is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.