Diagnosis: Metastatic lung cancer
Treatment: Increase Consumer Directed Personal Assistance Services: Total of 30 Hours Per Week
The insurer denied: Increase Consumer Directed Personal Assistance Services: Total of 30 Hours Per Week
The denial is overturned.

This adult female patient is appealing the denial of an increase of consumer directed personal assistance services for a total of 30 hours per week. The plan has approved 15 hours per week. The patient is reported to have unsteady gait, amnesia, poor coordination, pain, and fatigue. There is a letter from the Provider noting that the patient has metastatic lung cancer and her condition is rapidly deteriorating. She is confined to the bed and depends on caregiver for activities of daily living. The patient's daughter has provided a statement that since the assessment in May, the patient is "unable to stand up, sit down, prepare for food, move around the home including going to the bathroom (even with a walker) by herself." She notes that the patient is also bedridden for most of her day.

The proposed treatment is medically necessary.
Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.

This patient has metastatic lung cancer. She is appealing denial of an increase in consumer directed personal assistance services (CDPAS) for a total of 30 hours per week. The plan has approved 15 hours per week. The provider notes that the patient's condition is rapidly deteriorating. The daughter notes the patient's condition has deteriorated since May and she is mostly bedridden. She needs assistance with activities of daily living and ambulation with a walker. The information provided supports that the member needs assistance that is not covered with the approved CDPAS 15 hours per week. The proposed increase in CDPAS to 30 hours per week is medically necessary.