Diagnosis: Heart failure, history of stroke, chronic kidney disease, hypertension, and dementia
Treatment: Consumer Directed Personal Assistance Services 8 hours per Day, 7 Days Per Week (Monday through Sunday) A Total of 56 Hours per Week
The insurer denied: Consumer Directed Personal Assistance Services 8 hours per Day, 7 Days Per Week (Monday through Sunday) A Total of 56 Hours per Week
The denial is overturned.

This patient is an elderly female. Her medical conditions include heart failure, history of stroke, chronic kidney disease, hypertension, and dementia. She has a recent diagnosis of
pericardial effusion and pleural effusions. She lives with her stepdaughter, who is her Consumer Directed Personal Assistance Services (CDPAS) personal assistant and assists past CDPAS (Consumer Directed Personal Assistance Services) hours. Denial of consumer directed personal assistance services for a total of 56 hours per week is being appealed. The health plan approved 43 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 3 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, transportation, bathing, dressing, and toileting; extensive assistance with personal hygiene; and limited assistance with walking, locomotion, bed mobility, and eating. She has frequent bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with personal hygiene, toilet use, bed mobility, and eating.

The Consumer Directed Personal Assistance Services 8 hours per Day, 7 Days Per Week (Monday through Sunday) A Total of 56 Hours per Week are 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. The patient receives consumer directed personal assistance services for a total of 43 hours per week. Denial of increase to 56 hours per week is being appealed. This patient has multiple chronic conditions, including recent diagnosis of pericardial effusion and pleural effusions. Uniform Assessment System (UAS) evaluation completed 3 months ago shows she needs assistance with all activities of daily living. She has frequent bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with personal hygiene, toilet use, bed mobility, and eating. The information provided shows that this patient has significant limitations in functioning. Her medical conditions have progressed, and there has been a significant decline in her level of functioning between Uniform Assessment System evaluations. The patient's impairment and level of assistance needed with activities of daily living support an increase in CDPAS (consumer directed personal assistance services) to a total of 56 hours per week.