Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hypertension, Parkinson's Disease and Shy-Drager Syndrome
Treatment: CDPAS (consumer-directed personal assistance service) Level 2 Services: 12 Hours (Split Shift) for a Total Amount of 168 Hours per Week
The insurer denied CDPAS (consumer-directed personal assistance service) Level 2 Services: 12 Hours (Split Shift) for a Total Amount of 168 Hours per Week.
The denial is upheld.

This is an adult female with Hypertension, Parkinson's Disease and Shy-Drager Syndrome. The request is for CDPAS (consumer-directed personal assistance service) hours to 
two 12 hour split shifts from her currently approved CDPAS (consumer-directed personal assistance service) 40 hours per week. A final adverse determination noted that the health plan partially approved the request, and that approval stays at CDPAS (consumer-directed personal assistance service) 49 hours per week. The denial letter argued that 49 hours a week is sufficient to meet current care needs. In a physician written appeal letter, the provider notes that the patient has multiple chronic medical conditions and requires assistance with daily needs as well as toileting and bed-repositioning. The letter argues that "she cannot be left alone safely and needs to have assistance during both day and night." A caregiver letter argues that the patient cannot get out of bed or walk around the apartment when the aide leaves and "is in need of home attendant services for 24 hours 7 days a week to ensure that she is safe." A nursing assessment dated 4 months ago notes that the patient requires total dependence for meal preparation and housework, maximal assistance for bathing and lower body dressing, and extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toilet transfer and use. She requires assistance with bed mobility and eating. An Aide Tasking Tool dated 4 months ago estimates requirements between 6 hours and 35 minutes and 6 hours and 50 minutes per day to address the patient's care needs for a total of 46 hours and 36 minutes per week.

The CDPAS (consumer directed personal assistance service) Level 2 Services: 12 Hours (Split Shift) for a Total Amount of 168 Hours per Week is not 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. The request is for an increase in Consumer Directed Personal Assistance Services (CDPAS) to a Split Shift, which represents a total of 168 hours per week. The submitted documentation does not reflect which activities of daily living cannot be completed within the currently approved 49 hours per week. Time for housework, meal preparation, personal hygiene, toileting, and dressing, have already been accounted for in the hours approved by the plan. Moreover, the CDPAS (consumer directed personal assistance service) program allows the patient's designated representative the flexibility to allocate the approved hours in a way that best meets the patient's needs. The patient is also noted to have equipment at home to assist with her activities of daily living and keep her safe, including a Walker, cane, bathroom assistive device, Chux, and liners. Notes also indicate that the patient will request a commode and wheelchair from the primary provider. 
Moreover, there is no evidence that the patient has skin breakdown or ulcers necessitating frequent repositioning at night. There is no evidence that the patient has tried and failed measures such as bathroom training and reducing fluid intake at night to help manage urinary incontinence. While the provider and caregiver letters indicate that the patient will be unsafe during periods when there is no aide present, personal care services are not covered for supervision and safety concerns, per New York State Guidelines. Based on the available information, the plan's initial denial rationale is appropriate, and 49 hours per week of CDPAS (consumer directed personal assistance service) hours are sufficient to meet the patient's needs. Thus, the increase in CDPAS (consumer directed personal assistance service) to Split Shift for a total of 168 hours per week is not medically necessary.