Diagnosis: multiple sclerosis
Treatment: home health care
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 24 Hours of Continuous Care with 12-Hour Split Shifts, 7 Days per Week.
The health plan's determination is overturned.

This is a case review for a female with medical history notable for multiple sclerosis, mobility issues, and bladder incontinence. The patient and her care team requested an increase to 24 hour continuous care with 12 hour split-shifts, 7 days per week.

The requested Consumer Directed Personal Assistance Services (CDPAS): 24 Hours of Continuous Care with 12-Hour Split Shifts, 7 Days per Week is medically necessary for this patient.
The patient's multiple sclerosis has resulted in severe limitations in performing activities of daily living (ADL) and Instrumental activities of daily living (IADL). She is dependent on others for all tasks, including toileting and bed mobility. She is incontinent of urine. Her husband has been providing informal support during the time that the patient does not have an aide available, but he will be undergoing major surgery in the near future. The patient is essentially bedbound without an aide available. The patient's personal care needs can be expected to be continuous in nature and unscheduled. She will require assistance throughout the day and night to help with toileting, bed mobility, and other personal care tasks.