Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Status post COVID-19 pneumonia. 

Treatment: Consumer Directed Personal Assistance Services (CDPAS); 24-hour continuous care, 7 days per week. 

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS); 24-hour continuous care, 7 days per week. 

The denial is overturned. 

This is a female patient with a medical history of diabetes, hypertension, recent deep vein thrombosis (DVT), dementia, arthritis, pressure ulcers, dysphagia, percutaneous endoscopic gastrostomy (PEG) tube, failure to thrive, status post COVID-19 pneumonia. The patient lives alone and the family has requested 24 hour services based on increased needs. 

Per the physician's order for personal care/consumer directed personal assistance services (CDPAS), the patient is bed and wheelchair bound; a Hoyer lift is used for transfers. Per the Telephone Assessment Tool, the patient was currently receiving 168 hours/day x 7 days. She had a wheelchair, hospital bed, Geri chair, Hoyer lift, shower chair, diapers and liners. Her ability to make decisions and overall self-sufficiency had declined. Total dependence was required for meals (on continuous enteral feedings minus a 4 hour break), managing medications (via gastrostomy tube), bathing, personal hygiene, dressing, and toileting and bed mobility. Frequent bladder and bowel incontinence was noted. The past Uniform Assessment System (UAS) report documented severe dementia. Family members assisted with patient's care and were requesting more assistance. 

The prior provision for 18 hours/day was based on the patient's pre-COVID status. She now has a PEG tube and is now totally dependent in all functions. She now uses oxygen at home. Aides' notes indicate unscheduled services being needed multiple times at night, making a provision for at least 5-hours sleep for the aide unavailable. The family visits and provides some services but do not appear to reliably replace the services provided by an aide. The patient does not live with family. She is alert but severely demented. 

In Managed Long Term Care (MLTC) Policy 16.07 it is noted that informal support is voluntary only. 

As noted in New York Codes, Rules and Regulations, Title: Section 505.14 Personal care services (2016), "continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep." 

The prior provision of 18 hours/day is no longer sufficient to meet the needs of the patient, due to deterioration in the patient's status. She requires 24 hour/day services. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for CDPAS; 24-hour continuous care, 7 days per week is substantiated. The insurer's denial is overturned.