Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, bronchiectasis, iron deficiency, traumatic fracture, malignant neoplasm of the large intestine, and osteoarthritis.
Treatment: Consumer directed personal assistance services (CDPAS) 7 days per week, 8 hours per day; 56 hours per week.
The insurer denied coverage for consumer directed personal assistance services (CDPAS) 7 days per week, 8 hours per day; 56 hours per week.
The denial is overturned.

This patient has extensive medical history associated with functional impairment and needs assistance for all ADLs (activities of daily living) and IADLs (independent activities of daily living). The patient lives alone. She receives some informal support from her children, but she mostly depends on personal care services (provided as Consumer Directed Personal Assistance Services CDPAS) for assistance with daily tasks. The patient has been receiving CDPAS 5 hours per day, 7 days per week; 35 hours per week total. The patient (via designee) requested CDPAS 56 hours per week, 8 hours per day, 7 days per week, which was denied. An external appeal was requested.

The most recent UAS provided was reviewed. The functional status report for IADLs indicated patient needed maximal assistance for meal preparation, ordinary housework; extensive assistance for managing finances and medications, transportation, shopping, stairs, equipment management; limited assistance for phone use. For ADLs, the patient needed maximal assistance for dressing lower body; extensive assistance for bathing, toilet use, bed mobility; limited assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet, eating.

Considering the patient's medical history, associated with functional decline, it is medically necessary for the patient to have caregiver support for all ADLs and IADLs throughout the day; including routine daily tasks (e.g., meal preparation/service, housekeeping tasks, bathing, personal hygiene, dressing, eating), and ADLs that occur at unscheduled and recurring times throughout the day (e.g., toileting, incontinence care, transfers, out-of-bed mobility including walking and/or wheelchair). Without adequate caregiver support the patient is high risk for adverse medical events, including falls/injury, skin damage (e.g., due to incontinence), malnutrition, dehydration. In addition, assistance from the CDPAS aide with the nebulizer, when needed at various times of the day, is medically necessary to help stabilize the patient's breathing and help prevent complications due to inability to clear secretions.

MLTC (managed long-term care) policy 16.07 states that managed long term care plans must assure that the plan of care can meet any of the patient's unscheduled or recurring daytime or nighttime needs for assistance. Therefore, the patient's need for assistance with mobility, toileting, meals, and in this case, CDPAS assistance with nebulizer treatments and skin care (all of which occur at unscheduled and/or recurring times during the day) must be considered in the determination of CDPAS hours. 

Considering the request for this external appeal is for CDPAS 56 hours per week, 8 hours per day, 7 days per week, it is reasonable to conclude that there are no other caregivers who can assist the patient for that period of time each day on a routine long-term basis. As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services (in this case CDPAS) are indicated to provide assistance with ADLs and IADLs when needed. 

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

The insurer's denial of coverage for consumer directed personal assistance services (CDPAS) 7 days per week, 8 hours per day; 56 hours per week is overturned. Medical Necessity is substantiated.