Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease and Diabetes

Treatment: CDPAS (consumer directed personal assistance services) for 49 hours per week

The insurer denied coverage for CDPAS for 49 hours per week.

The denial is overturned.

This patient has various medical conditions affecting her ability to perform daily activities. She lives alone. The records indicate the patient has some informal help with daily activities from family, but the patient primarily relies on personal care services, provided as Consumer Directed Personal Assistance Services (CDPAS). She has been receiving CDPAS 40 hours per week. The patient reported difficulty managing daily tasks and requested an increase of CDPAS hours. The insurer's final denial letter included one statement that reported the patient requested CDPAS 49 hours per week, and another statement indicating request for 56 hours per week. The review organization representative contacted the insurer for clarification. The response indicated the patient requested CDPAS 49 hours per week, which was denied 

MLTC (Managed Long-Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, the patient's need for assistance with transfers, walking and toileting that occurs at various unscheduled times throughout the day must be considered in the determination of the patient's personal care service hours.

Regarding toilet use, the patient has poor manual dexterity which can interfere with proper cleaning. It is also likely she has difficulty with clothing adjustment before and after using the toilet, as she has limited use of her left arm, and needs extensive assistance for lower body dressing. It does not appear that supervision is adequate to safely and effectively manage the patient's care needs during toileting.

The UAS (Uniform Assessment System) reports the patient has occasional urinary incontinence; however, with the patient's slow, unsteady gait, it is possible that incontinence may increase. When she needs to reach the bathroom quickly, she may not reach the toilet in time. When the patient does not have caregiver assistance, mobility is more difficult, and episodes of incontinence may occur more often due to increased time needed to reach the toilet (i.e., functional incontinence). During daytime hours, a commode is not an adequate solution, as the patient may not always be near the commode. When there is an immediate need to reach the toilet, transfers and walking are often done in haste and with less regard for safety, which also increases the risk for falls. Considering the patient has impaired function of hands and left arm and needs assistance with lower body dressing, it is reasonable to expect that the patient needs assistance for incontinence care. Inadequate incontinence care can lead to incontinence-associated skin damage (e.g., dermatitis, fungal infection). 

The patient needs extensive assistance with morning and evening ADLs (activities of daily living), including bathing and dressing. Personal hygiene was noted as needing only setup help, but with report of poor manual dexterity and limited left arm function, it appears some assistance may be necessary. Regarding meals, the patient needs maximal assistance for meal preparation and service (setup help needed for eating). CDPAS hours can be flexible, but it is unknown whether the aide is present at all mealtimes. 

Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unable to provide care on a regular basis, then personal care services are indicated to provide necessary assistance for daily activities, including ADLs that occur at various and unscheduled times throughout the day. The patient requested CDPAS 49 hours per week. 

The health care plan did not act reasonably and with sound medical judgement or in the best interest of the patient.

The insurer's denial of coverage for consumer directed personal assistance services (CDPAS) for 49 hours per week is overturned. Medical necessity is substantiated.