Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia; Osteoarthritis; Diabetes Mellitus; Atrial Fibrillation

Treatment: Consumer Direct Personal Aide Service (CDPAS) 7 days x (2) 12 hours split shift

The insurer denied coverage for Consumer Direct Personal Aide Service (CDPAS) 7 days x (2) 12 hours split shift.

The denial is overturned.

This male patient has a medical history of benign prostatic hyperplasia, hypertension, hyperlipidemia, frontotemporal dementia, osteoarthritis, diabetes, and atrial fibrillation. He lives at home with his wife who is his primary caregiver. The patient has extensive medical history and significant functional impairment. The patient is forgetful at times and needs reminders to take his medications.  He was able to demonstrate how to safely call 911 in case of emergency.  He is totally dependent for meal preparation, housework, managing finances, managing medications, and shopping, and needs maximal assistance for telephone use.  The patient requires extensive assistance for managing stairs, transportation, bathing, and dressing lower body.  He needs limited assistance for personal hygiene, dressing upper body, walking, locomotion, transfer to toilet, toilet use, and bed mobility, and requires supervision for eating.  He has daily incontinence of bladder and bowel and uses diapers daily.  It is noted the patient transfers and ambulates with a rolling walker and contact guard and needs cueing supervision with walking.  

His wife has been providing nighttime care.  It is reasonable to conclude that she is requesting aide services for the night because she does not feel she can continue to provide care during the night. There is no documentation in the available records identifying any other informal caregivers who can provide extended hours of care to the patient on a daily basis.  Without informal caregivers who can provide care when needed, then personal care services (in this case CDPAS) are indicated to provide assistance with daily activities, including activities of daily living (ADLs) that occur throughout the day and night.

Based on the patient's need for incontinence care/toileting and repositioning, the frequency of care does not appear consistent with service hours for a live-in aide; i.e. care must be sufficiently infrequent so that a live-in aide can have 5 hours of uninterrupted sleep per day on a regular basis (as per NYS regulations for live-in aide services).  In addition, the Uniform Assessment System (UAS) indicates the patient and wife live in a one bedroom apartment and as per case notes, the wife reports there is no room for a live-in aide.  As per New York State regulations for personal care services, if a patient qualifies for a live-in aide, but there are no sleeping accommodations for the aide, then continuous services must be authorized. 

At this time based on available information of the patient's medical and functional status, probable frequency of assistance needed, and reported lack of sleeping accommodations for a live-in aide, continuous services (i.e. split shift) are indicated.  

Consumer Direct Personal Aide Service 7 days x (2) 12 hours split shifts is medically necessary. 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 7 days x (2) 12 hours split shift is reversed.  The medical necessity is substantiated.