Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic pain, peripheral vascular disease, bladder cancer, chronic obstructive pulmonary disease, dorsalgia, diabetes, and human immunodeficiency virus (HIV)
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 91 hours per week (Live-In)
The insurer denied the Consumer Directed Personal Assistance Services (CDPAS): 91 hours per week (Live-In).
The denial is overturned.

This elderly male has conditions including chronic pain, peripheral vascular disease, bladder cancer, chronic obstructive pulmonary disease, dorsalgia, diabetes, and human 
immunodeficiency virus (HIV). He is appealing denial of increase consumer directed personal assistance services (CDPAS) for the amount of 91 hours per week (live-in). The health plan approved 36 hours per week.

Uniform Assessment System (UAS) evaluation completed 7 months ago shows independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with stairs, transportation, bathing and power body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; independent with bed mobility and eating; supervision with managing finances and medications; and set up with phone use.
An appeal statement from New York State notes the patient needs live-in assistance for unscheduled toileting during day and night. It is reported that the patient is incontinent of bladder and goes to the bathroom one to two tines per night. He sleeps five to six hours per night. A log shows the patient requires overnight assistance with meal preparation, personal hygiene feeding, toileting medications, and incontinence care. Letter from providers state the patient's condition is declining. He has fallen down the steps multiple times. He needs assistance with all activities of daily living (ADLs) due to chronic pain syndrome and chronic fatigue syndrome.

The proposed treatment 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. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding. Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs), health maintenance activities and routine support services. This patient has multiple chronic conditions. He is appealing denial of increase consumer directed personal assistance services (CDPAS) for 91 hours per week (live in). The health plan approved 36 hours per week. Uniform Assessment System (UAS) evaluation completed 7 months ago shows the patient needs assistance with all activities of daily living, except bed mobility, eating, and managing finances and medications. He has bladder incontinence. Appeal statements indicate the patient's condition is declining and he has day and night unscheduled needs that include meal preparation, personal hygiene feeding, toileting medications, and incontinence care. This need is supported by the activity log. This patient's physical functioning is significantly impaired requiring assistance throughout the day and night. However, his needs are not such that an aide cannot get five hours daily of uninterrupted sleep.

The approved consumer directed personal assistance services (CDPAS) 36 hours per week is insufficient to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care. The proposed increase consumer directed personal assistance services 91 hours per week is medically necessary.