Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Multiple Sclerosis.
Treatment:  Consumer and Self-Directed Personal Assistance Services (CDPAS) 70 hours per week.

The insurer denied coverage for Consumer and Self-Directed Personal Assistance Services (CDPAS) 70 hours per week.  The denial is overturned. 

This female patient has multiple sclerosis (MS). She has mild paraparesis, is ataxic and uses a walker to ambulate. She also has urinary incontinence for which she is followed by a Urologist. Magnetic resonance imagining (MRI) of the brain showed diffuse and severe white matter disease and volume loss with compensatory enlargement of the lateral and third ventricles; low signal intensity on 1-weighted imaging and flair is compatible with black holes and axon destruction, a pattern compatible with chronic demyelinating disease. There is involvement of the anterior temporal lobes that is atypical and may be indicative of the severity of disease, but can also be seen in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). She does well with a rollator. The patient has reportedly declined and her mental status is a contributory factor; she is more dependent on the walker, and needs more help at home. She is incontinent and needs frequent unscheduled cleaning.  

The insurer has denied coverage for Consumer and Self-directed Personal Assistance Services (CDPAS) 70 hours per week and approved 42 hours per week. They state the patients' needs can be met with the current services. The patient's Neurologist states that the patient requires the requested hours related to her incontinence, need for hands on assistance, frequent falls, extreme fatigue, poor endurance, and the inability to independently attend to her activities of daily living (ADLs). The Neurologist also states that the patient has significant cognitive decline and requires an attendant to go to appointments, including physical therapy.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 7/6/16:
 
"(a) Definitions and scope of services.
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse."

The patient's functional status has declined; she is frequently and unpredictably incontinent and needs more assistance in toileting and cleaning. Her cognitive functioning has declined. The extra hours requested are not only for supervision and companionship. 

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

The insurer's denial of Consumer and Self-Directed Personal Assistance Services (CDPAS) 70 hours per week is overturned.  The medical necessity is substantiated.