Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Multiple Sclerosis
Treatment: Increase Consumer Directed Personal Assistance to 40 Hours per Week
The insurer denied: Increase Consumer Directed Personal Assistance to 40 Hours per week
The denial is partially overturned.

The patient is an adult male with multiple sclerosis who was initially approved for 3.5 hours per day, 6 days per week (total 21 hours per week) of Consumer Directed Personal Assistance Program. The request is for an increase in Consumer Directed Personal Assistance Program (CDPAP) Services to 8 hours per day, 5 days a week for a total of 40 hours per week. The most recent Uniform Assessment System (UAS) evaluation completed last month reflects that the patient is totally dependent for housework. He requires maximal assistance with shopping and extensive assistance with both medications and bathing. Limited assistance is required for personal hygiene and dressing the upper body. He is independent (set up only) for toilet use and eating. The evaluation notes that the patient uses assistive devices for locomotion indoors and scooter outdoors. A time-based task tool dated last month notes that the patient requires 4.5 hours per day to accomplish activities of daily living, with a total of 27 hours per week needed.

An initial adverse determination was issued, and a final adverse determination letter was issued recently upholding the initial denial. The denial language notes that the consumer directed personal assistance program (CDPAP) hours would remain the same at 3.5 hours per day, 6 days per week for a total of 21 hours per week. The rationale for denial further notes that time has been allotted for housework, laundry, and meal preparation and that granting time for additional hours when tasks are not being performed is not medically necessary. 

Appeal letters from the patient's physician notes that the increase to 40 hours per week is necessary because of the patient's gait instability, his elevated risk of falls, his dizziness and blurred vision, and his need for assistance with dressing, cooking, cleaning, and showering. The appeal letter notes that the patient is "functionally non-ambulatory" and is incontinent of bowel and bladder at times. Additionally, the letter points out that the most recent nursing assessment estimates a need of 27 hours per week of assistance.

The proposed increase in consumer directed personal assistance to 40 hours per week is not medically necessary; however, an increase to 27 hours per week is medically necessary.

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 request is for an increase in consumer directed personal assistance services to eight hours per day, five days per week, for a total of 40 hours per week. Based on the most recent in-home nursing assessment and tasking tool from last month, the patient's functional status is such that 27 hours per week are required to adequately meet his needs. Based on the tasking tool, there are activities of daily living which cannot be completed within the currently approved 21 hours per week. However, the appeal documentation does not reflect which activities of daily living cannot be completed within the 27 hours per week estimated by the tasking tool and for which 40 hours per week are required. The consumer directed personal assistance program allows the 
patient's designated representative the flexibility to allocate the approved hours in a way that best meets the patient's needs. The plan notes that the patient also has appropriate medical equipment in the home, including a cane, motorized wheelchair and scooter, shower grab bar, and personal emergency response system which can assist with the patient's needs. Additional hours beyond the estimated 27 hours per week from the tasking tool would thus be primarily for supervision and safety concerns. However, personal care aide services cannot be approved for the purpose of supervision, per New York State Guidelines.

Based on the available information, the plan approved hours (21 hours per week of consumer directed personal assistance) are not sufficient to adequately meet the patient's needs. However, the proposed treatment (i.e., increase in Consumer Directed Personal Assistance to 40 hours per week) exceeds the patient's needs and is thus not medically necessary. An increase to 27 hours per week, as based on the recent in-home nursing assessment, is medically necessary and appropriate.