Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiopulmonary disease. 
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week (split shift), for a total of 168 hours a week.

The insurer denied coverage for CDPAS 24 hours a day, 7 days a week (split shift), for a total of 168 hours a week.  The denial is overturned. 

This is a female patient who had a significant change in medical and functional status. She lives with her daughter and was receiving personal care services (PCS) which have met her daily care needs in the past. Her daughter works outside the home, and so it appears the patient was able to spend some time alone safely when neither the aide nor the daughter was with the patient. Due to a stroke and cardiopulmonary complications, the patient's daily care needs have increased. The daughter requested an increase of PCS to 24 hours split shift, which was denied by the insurer. The patient had been receiving aide services as Consumer Directed Personal Assistance Services (CDPAS) 42 hours per week. The insurer increased CDPAS to 24 hours (live-in) x 7 days per week to provide the patient with assistance with bi-level positive airway pressure (BiPAP), repositioning, and toileting 1-2 times at night.

The functional assessment of the Uniform Assessment System (UAS) report indicated the patient needed maximal assistance or total dependence for household related tasks, meal preparation, shopping; and extensive assistance to manage finances and medications. The patient was non-ambulatory, relying on wheelchair for mobility in the home. She needed maximal or extensive assistance for most other activities of daily living (ADLs), except bed mobility and eating were noted as independent setup help. She has physical and sensory impairments, which appear to have a substantial effect on her ability to perform daily activities, but it is likely that cognitive deficits adversely affect her ability to perform some daily tasks due to memory impairment and poor judgment/safety awareness. The patient's ability to perform daily activities is significantly impaired from the combined effects of the following: she had a recent stroke which resulted in significant residual deficits; cognitive changes; cardiopulmonary disease; obstructive sleep apnea and chronic obstructive pulmonary disease; and osteoarthritis. 

The patient's change in medical condition and functional status has resulted in a significant change in the level of care and frequency of care she requires. Considering her medical history, recent medical events and her current functional status, it is medically necessary for the patient to have caregiver assistance throughout the day and night for all routine instrumental activities of daily living (IADLs) and ADLs; assistance for unscheduled ADLs; repositioning several times at night in her recliner (to help with respiration and for pressure relief); plus providing assistance with BiPAP/oxygen if the patient removes the mask at night. Without assistance through the day and night, the patient is at risk for adverse health and safety events, including falls/injuries, skin damage (from incontinence, pressure), respiratory distress (if she is poorly positioned or her BiPAP mask is off).

Assistance from informal caregivers is voluntary as per New York State regulations for PCS. Based on the patient's medical history, functional impairments, and the description by the daughter of the type of care and the frequency with which she provides care at night, it does not appear that a live-in aide would meet the patient's care needs; as assistance would not be available during the aide's 5-hour sleep period each night. 

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

The carrier's denial of coverage for CDPAS 24 hours a day, 7 days a week (split shift), for a total of 168 hours a week is overturned. The medical necessity is substantiated.