Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic brain injury; cognitive and emotional impairments. 

Treatment: Consumer Directed Personal Assistance (CDPAS) services of 84 hours per week. 

The insurer denied coverage for Consumer Directed Personal Assistance (CDPAS) services of 84 hours per week. 

The denial is upheld. 

This is a female patient with a past medical history of multiple concussions secondary trauma, chronic traumatic encephalopathy, attention deficit hyperactivity disorder, depression, bipolar disorder, anxiety, insomnia, vertigo, hyperlipidemia, hypertension and pre-diabetes.  A telephonic New York State Department of Health's Uniform Assessment System (UAS-NY) report notes that the patient lives in a private home with a partner and others.  The patient suffers from short term and procedural memory loss due to a traumatic brain injury from years of trauma.  The patient is followed monthly by her psychiatric nurse practitioner for therapy due to several mental health diagnoses and for medication oversight.  The patient struggles with completing housework tasks.  The patient needs maximum assistance with meal preparation, managing finances, shopping and managing medications. Her friend helps manage her medications by calling in refills, picking up the medications from the pharmacy and handing her the pills to take.  She needs extensive assistance with ordinary housework, phone use and transportation. The patient needs supervision with oversight or cueing for bathing, personal hygiene, dressing her upper body, dressing her lower body, walking, locomotion, toilet transfer, toilet use and eating.  She is independent with bed mobility.  The patient uses an assistive device for locomotion indoors.  The patient is frequently bladder incontinent but bowel continent.  She suffers from urge and stress incontinence.  The patient uses liners and plans to follow up with her gynecologist about treatment options.  An increase to Consumer Directed Personal Assistance (CDPAS) services of 84 hours per week is being requested.

The patient has traumatic brain injury and psychiatric problems with resulting cognitive and emotional impairments.  Office visits and evaluations document such problems. A prior UAS report notes impairments in Instrumental Activities of Daily Living (IADLs) and independence in Activities of Daily Living (ADLs).  A more recent UAS report notes that she needs more assistance with IADLS and supervision with ADLs.  There is no documentation of new medical problems or of hospitalizations.  

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The patient has had behavioral and cognitive problems going back years that interfere with her ability to do IADLS and ADLs.  There has been some change in what was noted in a prior UAS report when compared to the more recent UAS report but supervision only is required for ADLs.  She has not had new impairments from other illnesses.  The insurer has appropriately weighed the impairments.  

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance (CDPAS) services of 84 hours per week is upheld.  The medical necessity is not substantiated.