Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease (ESRD), vesico-vaginal fistula, diabetes, gastroesophageal reflux disease (GERD), hypertension

Treatment: CDPAS (consumer directed personal assistance services) 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours in a week

The insurer denied coverage for CDPAS 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours in a week.

The denial is overturned.

This female patient has a complicated medical history that has required extensive treatment, including multiple medications and procedures. She has end stage renal disease (ESRD) receiving hemodialysis (HD) 3 times per week. She has substantial functional impairment requiring assistance with all daily activities. She receives personal care services as Consumer Directed Personal Assistance Services (CDPAS). 

Regarding cognition, the patient does not appear to have significant cognitive impairment. Mini-Mental State Exam (MMSE) score was 28/30. She was oriented to person, place, and time. Decision making for daily tasks was described as modified independence (some difficulty in new situations only); short term, procedural and situational memory were ok; but she is forgetful at times. She needs reminders for medications. Overall, it appears the patient's functional decline is primarily due to physical impairment from various medical conditions. Cognitive changes (some forgetfulness) appear to have limited effect on daily activities. 
                                                                                    
The patient's care needs from morning to evening include all meal preparation, service and assist with eating; assistance with medications; household related tasks; routine morning and evening ADLs (activities of daily living); transfer via Hoyer lift in and out of bed/chair; all toileting/incontinence care when needed. It appears unlikely an aide would consistently sleep for 5 uninterrupted hours during the day from morning until evening ADLs. Nighttime care includes toileting/incontinence care (which occurs at unscheduled times); repositioning in bed for pressure relief (probably at least every 2-3 hours, which may occur at the same time as incontinence care if it occurs that often); repositioning for pain relief as needed; assistance with CPAP when it is displaced; initiation of morning ADLs to prepare patient for departure to dialysis. The frequency of care needed to attend to these nighttime/early morning care needs does not appear compatible with the sleep requirements for a live-in aide, i.e., 5 uninterrupted hours of sleep per day on a regular basis.  The patient's care needs do not meet criteria for live-in services; and therefore continuous (split shift) services are necessary.

The patient (via designee) is requesting CDPAS 168 hours per week; and so, it is reasonable to conclude that there are no informal helpers who are capable and available to provide the patient with assistance for daily activities on a regular basis during the day or night. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services (in this case CDPAS). When informal caregivers are unable to provide necessary care, then personal care services (in this case CDPAS) are indicated to provide assistance with all daily activities as needed during the day and night. Based on available information, it does not appear there is a consistent, predictable 5-hour time period each day when a live-in aide can have 5 uninterrupted hours of sleep as required by NYS regulations for live-in aides. Therefore, continuous services are necessary. If the family decides to use standard PCA (personal care assistant) services in combination with, or instead of CDPAS, continuous personal care services apply for PCA and CDPAS. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. Consumer Directed Personal Assistance Services 7 days per week, 24 hours per day continuous care by more than 1 person, 168 hours per week is medically necessary. 

The insurer's denial of coverage for consumer directed personal assistance services (CDPAS) 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours in a week is overturned. Medical Necessity is substantiated.