Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular Dementia, hypertension, hyperlipidemia, osteoporosis with low back pain, depression, and colon cancer status post chemotherapy. 
Treatment: CDPAS: 12hrs per day 1 day per week, 2hrs per day 4 days per week, and 7hrs per day 2 days per week, for a total of 34hrs per week. 
The insurer denied coverage for Consumer Directed Personal Care Assistance (CDPCA) services. 
The denial is overturned. 

According to the documentation submitted, this is the case of a patient with a history of Vascular Dementia, hypertension, hyperlipidemia, osteoporosis with low back pain, depression, and colon cancer status post chemotherapy. The patient needs extensive assistance with bathing, weight bearing, upper and lower body dressing and medications. She needs limited assistance with toilet use, toilet transfers, bed mobility and phone use. She  also needs maximal assistance with shopping, meal preparation and housekeeping. The patient's primary walking support is a cane but she needs help with weight bearing. The patient has requested 34 hours per week in split daily hours. The insurance company has approved only 12 hours per week. 

The NYS (New York State) Comprehensive Uniform Assessment System (UAS) form was reviewed. The patient has had no falls or hospitalizations in the last 90 days but has fallen in the past with right foot and ankle injury. She is also incontinent of bladder. Documentation on the UAS indicates that she needs every 4 hour pull up changes due to her incontinence. The patient needs extensive assistance with bathing, weight bearing, upper and lower body dressing and medications. She needs limited assistance with toilet use, toilet transfers, bed mobility and phone use. However, she needs maximal assistance with shopping, meal preparation and housekeeping. The patient's primary walking support is a cane but she needs help with weight bearing. She is able to use the PERS (Personal Emergency Response System) system or call 911 for emergencies. 

Consumer directed personal care assistance (CDPCA) hours are approved primarily to provide hands-on assistance for completion of instrumental activities of daily living (IADL) / ADL (activities of daily living) tasks when no one else is available to provide assistance.  Additional hours cannot be provided for safety monitoring only.  Safety monitoring is considered to be part of the qualifying tasks necessitating personal care services. 

Based on the documents reviewed, the patient's health and safety cannot be appropriately provided and maintained with only 12 CDPCA hours/week. She needs extensive assistance with bathing, upper and lower body dressing, weight bearing and reminders for medications. She is incontinent of urine and needs frequent changes.  Without these changes she would have an increased risk for skin breakdown and falls. It is noted that the patient lives alone and has no informal helpers. 

The insurer's denial of 22 additional hours of CDPCA per week is not medically appropriate. The decision to deny 22 additional hours of care for a total of 34 hours per week is reversed. The hours may be used flexibly as needed to maintain safety and to help the patient to remain in the community. 

Based on the above, the insurer's denial should be overturned. The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient. The medical necessity for consumer directed personal care assistance (CDPCA) services for 34 hours per week is substantiated based on the documentation provided.