Diagnosis: Legal blindness, macular degeneration, hallucinations, anxiety, chronic kidney disease, hypertension, degenerative joint disease, hypothyroidism, and atrial fibrillation.
Treatment: Increase Consumer Directed Personal Assistance Service (CDPAS) to 7 Days per Week, 24 Hours per Day, Live-in, for a Total of 91 Hours per Week.

The insurer denied: Increase Consumer Directed Personal Assistance Service (CDPAS) to 7 Days per Week, 24 Hours per Day, Live-in, for a Total of 91 Hours per Week.

The denial is upheld.

This elderly female has conditions including legal blindness, macular degeneration, hallucinations, anxiety, chronic kidney disease, hypertension, degenerative joint disease, hypothyroidism, and atrial fibrillation. She is appealing the denial of an increase in consumer directed personal assistance service (CDPAS) to seven days per week, 24 hours per day, live-in, for a total of 91 hours per week. The patient's family wants 24-hour care. The health plan approved consumer directed personal assistance service seven days per week, six hours per day, for a total of 42 hours per week.

Uniform Assessment System evaluation performed recently showed the patient has infrequent needs with grooming, dressing, bathing, transferring, toileting, meal preparation, and feeding. Medical records show stable medication regiment.

The proposed treatment is not medically necessary.

Personal assistance 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 multiple medical conditions. She is appealing the denial of an increase in consumer directed personal assistance service (CDPAS) to seven days per week, 24 hours per day, live-in, for a total of 91 hours per week. The health plan approved consumer directed personal assistance service seven days per week, six hours per day, for a total of 42 hours per week. It is noted that Uniform Assessment System evaluation performed recently showed the patient has infrequent needs with grooming, dressing, bathing, transferring, toileting, meal preparation, and feeding. The information provided does not support that the patient has functional needs supporting the requested increase in consumer directed personal assistance
service (CDPAS) to seven days per week, 24 hours per day, live-in, for a total of 91 hours per week. Based on all available information, the approved consumer directed personal assistance service seven days per week, six hours per day, for a total of 42 hours per week, is appropriate to meet this patient's needs for assistance with activities of daily living. The proposed consumer directed personal assistance service, live-in, is not medically necessary.