Diagnosis: chronic obstructive pulmonary disease (COPD), diabetes and ulcerative colitis

Treatment: consumer directed personal assistance services (CDPAS) 12 hours per day, 3 days per week, for a total of 36 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 12 hours per day, 3 days per week, for a total of 36 hours per week

The denial is overturned



This is an elderly patient with medical problems including chronic obstructive pulmonary disease (COPD), diabetes and ulcerative colitis. He lives alone in a private residence. The patient is currently approved for consumer directed personal assistance services (CDPAS) 30 hours per week 10 hours/day, 3 days/week and personal care services (PCS) 40 hours per week 10 hours/day, 4 days/week. He is requesting CDPAS 36 hours/week (12 hours/day, 3 days/week).

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as moderately impaired. He is reportedly totally dependence for completing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is also reportedly totally dependent for bathing, personal hygiene, dressing, locomotion and toilet transfer/use. Maximal assistance is reportedly needed for bed mobility and extensive assistance for eating. The patient is incontinent of bladder and bowel. There has been no significant functional decline or reported falls over the prior 90 days; however, the patient is non-ambulatory. He is essentially bed bound and totally dependent with significant cognitive deficits. The patient's condition (as documented by his treating physician) and functional deficits are at a level or unpredictable as to require the requested CDPAS 36 hours/week (12 hours/day, 3 days/week). Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by the requested CDPAS 36 hours/week (12 hours/day, 3 days/week).

Based on the above, the insurer's denial must be reversed. 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 consumer directed personal assistance services (CDPAS) 12 hours per day, 3 days per week, for a total of 36 hours per week is substantiated.