Diagnosis: Hypertension, cardiac arrhythmias, asthma, arthritis, general weakness, gait abnormalities, and overactive bladder

Treatment: increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.

The insurer denied coverage for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.

The denial is overturned

This is an elderly patient with chronic medical problems including hypertension, cardiac arrhythmia and osteoarthritis. The insurer approved consumer directed personal assistant services (CDPAS) 42 hours/week. The request is for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired. Maximal to extensive assistance is needed for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing. Extensive assistance is needed for personal hygiene, dressing, locomotion, ambulation (uses walker or cane) and toilet transfer/use. She is frequently incontinent of bowel and bladder. The patient is independent with bed mobility and eating. The patient fell in her bathroom and was able to activate Life Alert and obtained assistance. She also fell again and was sent to the emergency room (ER). The computed tomography (CT) scan was negative, and she was not admitted to the hospital. The patient was more recently admitted to the hospital and treated for pneumonia. She was subsequently discharged.

The patient's medical condition, functional ability and mobility are at the level as to require the requested consumer directed personal assistant services (CDPAS) services 24 hours/day, 7 days/week (live-in). She is frequently incontinent, has fallen in the bathroom along with recent falls and hospitalization, support an increase CDPAS services 12 hours/day, 7 days/week (total 84 hours/week). Given her recent hospitalization for pneumonia and likely self-sufficiency deterioration, an updated Uniform Assessment System (UAS) report may be indicated. Based on the records reviewed, the patient's health and safety would be more appropriately provided and maintained by increasing CDPAS services to 24 hours/day, 7 days/week (live-in).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in services is substantiated.