Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Interstitial pulmonary fibrosis, chronic respiratory failure, congestive heart failure, chronic myelogenous leukemia, diabetes mellitus type II, osteoporosis, sacral ulcer, cognitive impairment.

Treatment: Consumer Directed Personal Assistance Services (CDPAS) of 2, 12-hour shifts (24 hours per day), 7 days per week from Monday through Sunday, for a total of 168 hours per week.

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) of 2, 12-hour shifts (24 hours per day), 7 days per week from Monday through Sunday, for a total of 168 hours per week.

The denial is overturned.

This patient has a history of chronic myelogenous leukemia, diabetes mellitus type II, end stage interstitial pulmonary fibrosis (IPF), chronic respiratory failure, supplemental oxygen use, gait impairment, generalized weakness, urinary incontinence, sacral ulcer, congestive heart failure, osteoporosis, chronic pain, and cognitive impairment.  Per the New York State Department of Health's Uniform Assessment System (UAS-NY) the patient, who lives with family members, requires assistance with all activities of daily living (ADLs) and all instrumental activities of daily living (IADLs). An increase to consumer directed personal assistance services (CDPAS) of 2, 12-hour shifts (24 hours per day), 7 days per week from Monday through Sunday, for a total of 168 hours per week is requested.

Based on the description in the UAS (Uniform Assessment System), letters, and medical office records, it appears the patient is severely functionally impaired to the extent that she either has minimal or no participation in most daily activities. The patient received personal care services (PCS) as CDPAS 84 hours per week, 12 hours per day. A family member is an informal caregiver but is unable to provide the level of care required during non-CDPAS hours (evening/night). 

The patient's medical history includes multiple contributing factors to her functional decline. The patient has interstitial pulmonary fibrosis (IPF). The records indicated the patient has dyspnea with normal activities, severe fatigue, muscle weakness, decreased appetite. She requires continuous oxygen and use of a wheelchair for mobility due to hypoxia on exertion.  It is reported that the oxygen nasal cannula is displaced at night which results in hypoxia, and so a caregiver needs to be available to put the nasal cannula back in place. 

Considering the patient's medical history, functional status, and personal care needs, it is medically necessary for the patient to have caregiver assistance for all daily activities, including ADLs that occur during the day and night. The patient also needs a caregiver to assist with pain management (e.g., repositioning in bed, assist with medication); assist with correct placement of nasal cannula to ensure oxygen delivery; and facilitate prompt identification and action for episodes of hypoglycemia (with notification of family who are in the home). These interventions can help decrease risk of skin injury from incontinence and pressure, help prevent complications due to hypoxia and hypoglycemia, and possibly prevent falls/injury if patient tries to move off the bed.

At this time, it does not seem prudent to have a 24-hour live-in aide as the caregiver. A live-in aide needs to have 8 hours of sleep per day, including 5 uninterrupted hours of sleep (as per NYS [New York State] regulations for live-in aides). The plan that would best serve the patient's needs is personal care services (provided as CDPAS) 24 hours per day, split shift services.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Consumer Directed Personal Assistance Services of 2, 12-hour shifts (24 hours per day), 7 days per week from Monday through Sunday, for a total of 168 hours per week is overturned. Medical necessity is substantiated.