Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Cognitive impairment. 
Treatment: Consumer Directed Personal Assistance Services (CDPAS) Level II: 40 hours per week. 

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) Level II: 40 hours per week. 

The denial is overturned. 

This is a female patient with a past medical history of psychosis, insomnia, depression, dementia, hypertension, chronic obstructive pulmonary disease (COPD), heart failure, hyperlipidemia, and diabetes mellitus. The insurer approved Consumer Directed Personal Assistance Services (CDPAS) 8 hours per week. The patient (via designee) requested approval for CDPAS 40 hours per week. The patient has significant cognitive impairment which appears to be the primary cause of her need for assistance or supervision for various daily activities. The patient had been attending an adult day care program 5 days per week, until it was closed due to COVID-19. The patient has also been receiving CDPAS for 2 days per week, total of 8 hours. The patient's niece is the CDPAS aide. 

 A recent telephone assessment indicates patient is totally dependent or needs maximal assistance for most Instrumental Activities of Daily Living (IADLs). For Activities of Daily Living (ADLs), the patient needs limited assistance for bathing and lower body dressing, and supervision for most other ADLs, except bed mobility and eating (setup). The patient has a history of dementia, depression, and psychosis. There are no formal evaluations of the patient's cognitive status; but based on Uniform Assessment System (UAS) documentation, there is significant cognitive impairment. Decision making for daily tasks was noted as moderately impaired, with decisions consistently poor or unsafe; cues and supervision is needed at all times. Short term and procedural memory impairment was noted. She was unable to describe the steps in any task. It was noted she is unable to call for help. It appears her comprehension is impaired, as it was noted that she needs to have questions repeated or explained. 

The insurer apparently recognized the need and value of the day care program for the patient, as it was authorized by the insurer. When that service was no longer available, it appears that some type of alternate service was indicated. As there were no day care options, it appears the most reasonable alternative was to expand the patient's CDPAS hours which were already in place. The patient needs supervision, cues/prompting and/or assistance for most ADLs and IADLs. When a person is cognitively impaired and is unable to perform daily activities without some form of caregiver support, this is consistent with the scope of care for personal care services; in this case provided as CDPAS. 

Based on the records provided for review, it appears the patient has significant cognitive impairment, resulting in loss of ability to perform ADLs and IADLs independently. Therefore, it is medically necessary for the patient to have caregiver support to ensure proper and safe completion of ADLs and IADLs. The niece assumed responsibility for providing the assistance/supervision/direction the patient needed during the time period in question. The patient advocate indicated the patient's hours at day care 5 days per week totaled 40 hours per week. Providing these services through CDPAS appears to be an acceptable plan for provision of care, in place of the lost services from day care. Clarification was obtained from the insurer that this appeal is for retroactive authorization for CDPAS 40 hours per week for the time period in question only. 

CDPAS 40 hours per week, for the time period in question is approved. 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 the requested CDPAS Level II: 40 hours per week is substantiated. The insurer's denial is overturned.