Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident with residual right hemiplegia, type 2 diabetes mellitus, hepatic cirrhosis with portal vein hypertension and gastroesophageal reflux disease.
Treatment: Consumer directed personal assistance services (CDPAS) of 168 hours per week.

The insurer denied coverage for consumer directed personal assistance services (CDPAS) of 168 hours per week.  The denial is overturned.

The patient is a female with a past medical history of a cerebrovascular accident (CVA) with residual flaccid right hemiplegia, type 2 diabetes mellitus, hepatic cirrhosis with portal vein hypertension, and gastroesophageal reflux disease (GERD). Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her daughter were present on the call. The patient lives alone.  

Needs are: 
1) Total dependence for meal preparation, ordinary housework, managing finances, managing stairs and shopping;
2) Maximal assistance for transportation, equipment management, bathing and dressing her lower body;
3) Extensive Assistance for managing medications, personal hygiene, dressing her upper body, bed mobility, toilet transfer and toilet use;
4) Supervision/Independence for locomotion but needs setup help only. She uses a motorized wheelchair for locomotion.
5) Cognition:  There is mild impairment. 
6) Continence: The patient is frequently bladder incontinent and is infrequently bowel incontinent. She uses pads and briefs for incontinence. 

The patient was admitted to the hospital due to abdominal pain, and she was diagnosed with end stage liver failure. She was discharged home with her family on comfort care measures. The patient's daughter reported to the insurer that she is bedbound. The patient's daughter requested an increase in consumer directed personal assistance services (CDPAS) of 168 hours weekly. Per a medical video visit with her doctor, the patient was with her daughter and friend to discuss complaints of increasing pain and the need for ongoing pain management. The family was seeking additional home health care services before pursuing hospice care. During this visit, the patient and family have re-initiated a referral to hospice care, as the patient's liver failure has worsened, and she was noted to have poor health. An increase to CDPAS of 168 hours per week is being requested.

In a visit and a letter, the medical doctor (MD) certifies that the patient is bedbound. The same is true in a another letter from other professionals who have cared for her. 

The patient is a woman who has end stage cirrhosis and right flaccid upper extremity (UE) hemiplegia due to prior CVA. UAS was done. Since then, the patient has declined and is now bedbound. She has incontinence of bowel and bladder. The provision of diapers is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" in https://www.ncbi.nlm.nih.gov/ updated recently changing diapers regularly and positioning are also necessary. She is unable to clean herself, change her diaper, transfer, stand, ambulate or toilet by herself. Her needs are now 24/7 for scheduled and unscheduled tasks. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The reviewer disagrees with their assessment of the patient's functional ability.

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services of 168 hours per week is reversed. Medical necessity is substantiated.