Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, spinal meningioma with neurogenic bladder, history of fractures
Treatment: Increase in Consumer Directed Personal Assistance Services (CDPAS), Seven (7) Days x (times) Twenty-Four (24) Hours (Live-in)
The insurer denied the increase in CDPAS, 7 days x 24 hours (live-in).
The denial is overturned. 

This female has medical conditions including dementia, high blood pressure, T12 (twelfth thoracic vertebra) compression fracture, T4 (fourth thoracic vertebra) spinal meningioma with neurogenic bladder and history of left femur fracture.  She is appealing denial of an increase in consumer directed personal assistance services (CDPAS) to 24 hours per day, on a live-in basis.  She has been approved for CDPAS for four days a week for nine hours per day and three days per week for eight hours per day.  The patient lives with her son and daughter-in-law who is also a CDPAS aide.  Uniform Assessment System (UAS) evaluation completed shows modified independent cognitive skills and the following functional status: total dependence with meal preparation, housework, managing finances and medication, phone use, and shopping; maximal assistance with bathing, dressing, locomotion, toilet transfer; and extensive assistance with eating.  She is bed bound and requires repositioning.  She requires one-to-two person assistance for transfer.  Compared to a UAS evaluation performed a month prior, there has been a decline in functional status resulting in more assistance needed for bathing, dressing, and toileting.  The patient has a bladder catheter.  She is frequently incontinent of bowel.  

An appeal statement from New York State indicates that the patient is now paraplegic and has urinary incontinence, chronic pain and decubitus ulcers on the left sacrum as a result of a growing spinal meningioma causing spinal cord compression.  The statement notes that the patient's functional status has declined since UAS evaluation performed.  A letter from the provider states that the patient is unable to perform activities of daily living (ADLs) independently or move lower extremities as a result of recent growth of a spinal meningioma.  The physician recommends an increase is personal assistance services (PAS) hours because the patient is completely unable to care for herself.

Yes, the proposed increase in CDPAS to 7 days a week for 24 hours a day (live-in) is medically necessary.

The proposed increase in CDPAS to 7 days a week for 24 hours a day (live-in) is medically necessary because it is consistent with standard of care. Please see below for additional details.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs, including toileting, walking, transfers, turning/positioning, or feeding.  Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  

The patient has recently become paraplegic due to growth of a spinal tumor.  She is unable to care for herself.  She is appealing denial of PAS 24 hours a day on a live-in basis.  She was approved for 60 hours a week.  A UAS evaluation performed shows that the patient's functional status has declined since a UAS evaluation performed a month prior.  The patient is bed bound and requires repositioning/turning and one-to-two person assistance with transfers.  She requires assistance with all ADLs.  This patient has continuous needs that cannot be met with the approved PAS 60 hours per week.  The proposed increase in PAS to 24 hours per day (live-in) is medically necessary for this patient.