Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ischemic cardiomyopathy
Treatment: Personal care aide - 49 hours (hrs) per week
The insurer denied Personal care aide - 49 hours (hrs) per week.
The determination is overturned.

This is a male patient with a history of ischemic cardiomyopathy, coronary artery disease, chronic heart failure, hypertension, history of a stroke, acute stress reaction, major depressive disorder, adjustment disorder with anxiety, and mild cognitive impairment. The patient lives with his wife in a private home. The patient was previously approved for 28.5 hours per week of Consumer Directed Personal Assistance Services (CDPAS). The patient and his care team requested 49 hours per week of CDPAS. The Plan denied this request.
A video Uniform Assessment System (UAS) was completed. The patient was assessed at maximal assistance for the tasks of meal preparation, ordinary housework, managing finances, managing medications, stairs, shopping, transportation, and equipment management; extensive assistance with tasks of phone use, bathing, dressing lower body, and transfer toilet; limited assistance for tasks of personal hygiene, dressing upper body, walking, locomotion, and toilet use; and independent for tasks of bed mobility and eating. A tasking tool was used to determine that he requires 26.75 hours of aide service per week.
His PCP states that it is medically necessary to increase his home care service hours. The patient's PCP state that he has shortness of breath, dizziness, and unstable balance that is exacerbated while walking and bending. His PCP states that he needs constant supervision to prevent falling.
His therapist states that the patient's mental condition has changed and that he needs more help with dressing, bathing, cleaning, cooking, shopping, and going for walks outside. His therapist states that increased aide service is necessary to help the patient with personal care when he feels anxious and depressed. At issue is the medical necessity of Personal care aide - 49 hours (hrs) per week.

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Consumer Directed Personal Assistance Services 49 hours per week is medically necessary.
There is documentation in the UAS of the patient requiring extensive assistance with the task of transfer toilet and limited assistance with the tasks of walking, locomotion, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan did not document a plan to meet these unscheduled and unpredictable care needs. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. There is documentation from the patient's PCP of the medical necessity of increased personal assistance services. The patient lives with his wife and therefore has informal support. However, per New York Codes, Rules and Regulations (NYCRR) 505.14, the plan cannot assume that the informal support person can provide all needed care outside of the approved CDPAS hours as informal supports must be voluntary. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS hours is not solely for safety and supervision but to assist the patient with activities of daily living (ADLs).