Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 40 Hours a Week
The insurer denied Consumer Directed Personal Assistance Services (CDPAS) 40 Hours a Week.
The determination is overturned.

The patient has epilepsy and autism. His last seizure was almost 2 years ago. His medications comprise Keppra 750 milligrams (mg) twice daily, and clonidine 0.1 milligrams (mg) two tablets at night. His doctor describes that the patient has severe autism. He has no perception of safety and requires supervision at all times to keep him away from dangerous situations such as water, fire and stoves, ingestion of toxic substances and heights. He would not be capable of acting in an emergency, for example fire, flood or robbery. His provider noted that it was medically necessary for the patient to receive at least 40 hours of home care per week. At present he has been approved for 16 hours of Consumer Directed Personal Assistance Services (CDPAS) for assistance with dressing, bathing, toileting and housekeeping related services.
The Uniform Assessment System - New York Comprehensive Community Assessment Report was completed. The report describes that the patient lives in a private home with his parents, sisters , and grandmother, who does not work outside the house. His mother works. Her schedule may change. The father's work schedule varies. The patient is noted to attend a special education program. It is unclear if this is on hold during the pandemic.
In the section on cognition, he is noted to make decisions that become poor and unsafe in specific recurring conditions. He may require cues. He has short and long term memory problems. He is not self-directing and is not oriented to time. He has difficulty finding words and finishing thoughts. Prompting is usually required. He can be physically abusive, pushing others and resisting care. His vision and hearing are satisfactory. He is able to walk without assistance. He requires maximal or extensive assistance for activities of daily living, such as preparing meals, bathing, housework, managing finances, taking medication and making telephone calls. He is continent of bowel and bladder. He has not had recent emergency room visits or hospital admissions. Additional medical issues include constipation and insomnia.
The nurse concludes in the report that the patient can safely be left alone, but this statement is contradicted both by his Dr.'s letter, and by the documentation included in the body of the Uniform Assessment System - New York Comprehensive Community Assessment Report.
At issue in this case is whether Consumer Directed Personal Assistance Services (CDPAS) 40 Hours a Week are medically necessary.
Consumer Directed Personal Assistance Services (CDPAS) 40 Hours a Week are medically necessary. The patient cannot safely be left alone. Although the nurse who compiled the Uniform Assessment System - New York Comprehensive Community Assessment Report concluded that the patient could safely left alone, documentation included in the body of the report and his doctor's letter describe that the patient has no sense of danger, and requires significant supervision for activities of daily living. The patient requires limited assistance for toileting (requires physical guidance) and maximal assistance for meal preparation. He requires extensive assistance to make a telephone call, and so would not be able to summon help if an emergency situation arose during the hours in question (medical emergency or fire).  The Consumer-Directed Personal Assistance Program website describes that "Medicaid Consumer-Directed Personal Assistance Programs provide an alternative way of receiving home care services in which consumers have more control over who provides their care and how it is provided. Rather than assigning a home care agency that controls selection, training, and scheduling of aides, the "consumer," or the family member, friend, or guardian directing his or her care, performs all these functions usually done by the agency."[1,2,3]