Diagnosis: Multiple Sclerosis
Treatment: Consumer Directed Personal Assistance Services
for a Total of 56 Hours Per Week
The insurer denied: Consumer Directed Personal Assistance Services for a Total of 56 Hours Per Week
The denial is upheld

The patient is an adult male. His conditions include multiple sclerosis and visual impairment. Denial of Consumer Directed Personal Assistance Services for a total of 56 hours per week is being appealed. The health plan approved 11 hours per week.
The patient's Uniform Assessment System (UAS) evaluation completed 6 months ago shows minimally impaired cognition and functional status: total dependence with meal preparation; extensive assistance with housework, shopping, and dressing; limited assistance with managing finances; supervision with managing medications, stairs, transportation, bathing; and independent with phone use, personal hygiene, walking, toileting, locomotion, bed mobility and eating. He has infrequent urinary incontinence. A letter from the patient's provider notes the patient's MS (multiple sclerosis) has been worsening. He is more unsteady and has cognitive problems. He requires more assistance with ADLs (activities of daily living) as well as supervision at home.

The requested Consumer Directed Personal Assistance Services for a Total of 56 Hours Per Week 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. Denial of Consumer Directed Personal Assistance Services for a total of 56 hours per week is being appealed. The health plan approved 11 hours per week.
This patient has multiple sclerosis. Uniform Assessment System (UAS) evaluation completed 6 months ago shows he requires assistance with meal preparation, housework, shopping, dressing, and with managing finances. The appeal statement notes that the patient's gait is more unsteady, and he requires more assistance with ADLs (activities of daily living) as well as supervision at home. The information provided does to support that the patient's needs for assistance with ADLs (activities of daily living) cannot be met with the currently approved assistance of 11 hour per week. Consumer directed personal assistance services is not indicated supervision. The requested increase in assistance to 56 hours per week is not medically necessary.