Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision loss, pain, gait instability and a history of falls. 
Treatment: 42 hours per week of Consumer Directed Personal Assistance Services (CDPAS). 

The insurer denied coverage for 42 hours per week of CDPAS. 

The denial is overturned. 

This is a male patient who has advanced glaucoma and substantial vision loss (light perception only). He lives at home with a roommate. He has a niece who visits every day and assists him with daily activities. He was assessed for personal care services and was approved for Consumer Directed Personal Assistance Services (CDPAS) 15.75 hours per week. The patient requested an increase of services to 42 hours per week which was denied by the insurer; but CDPAS hours were increased to 21 hours per week. The patient (via designee) requested an external appeal.

The patient's functional status as reported in the Uniform Assessment System (UAS) report indicates the patient needs maximal assistance for housework, shopping and finances, and extensive assistance for other instrumental activities of daily living (IADLs), except meal preparation and phone use (limited assist). The patient needs setup help for most activities of daily living (ADLs); except supervision is needed for bathing and walking/locomotion. The patient's cognitive status as determined from the UAS report indicates the patient usually can make decisions for daily tasks; except for some difficulty in new situations; he is self-directing. The mini mental status exam (MMSE) identifies some short-term memory deficit and some impairment with calculations. Several questions of the MMSE were not done. The major factor contributing to the patient's functional impairment is his vision loss. The UAS indicates the patient has no vision in left eye and decreased vision in right eye. For this patient, some of his physical impairments (e.g. chronic pain) may cause functional limitations to his ability to perform daily activities in addition to his vision impairment. 

Considering the patient's history of vision loss, pain, gait instability and recent falls, it is medically necessary and in the patient's best interest to provide additional hours of assistance with daily activities to facilitate safe and effective performance of ADLs and IADLs. The patient requested CDPAS 42 hours per week. The schedule of daily hours should be allocated with consideration for assistance at meal times and for morning and evening ADLs (possibly split hours each day into more than one shift). Time should also be allocated to provide time for outdoor activity which includes assistance with stairs and supervision or assistance with walking outdoors. 

The UAS identifies only one informal caregiver, noted as a relative; most likely the niece. It is not known whether she still provides informal caregiver support. The UAS indicates the patient has a roommate who does not assist with ADLs or IADLs. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. The patient is requesting additional CDPAS hours; and so it is reasonable to conclude that there are no informal caregivers who can provide additional hours of support on a regular basis. When informal caregivers are unable to provide care on a consistent basis, then personal care services (in this case CDPAS) are indicated to provide necessary assistance to the patient for daily activities when needed. Additional hours will provide the patient with more support during hours of the day when he is most active and needs help with daily activities. 

CDPAS 42 hours per week are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The medical necessity for 42 hours per week of CDPAS is substantiated. The insurer's denial is overturned.