Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Difficulty ambulating: Chronic Pain
 
Treatment: Consumer Directed Personal Care Assistance Services, Level ll, 34 hours per week

The insurer denied the Consumer Directed Personal Care Assistance Services, Level ll, 34 hours per week. The denial was reversed.   

This is a male patient with a medical history of poor circulation, hypertension, renal cysts, lungs nodules, enlarged prostate, deep vein thrombosis, venous ulcers. It was reported that the patient had numerous venous ulcers that had been treated without surgery; however, due to his continued issues with ambulating and pain he recently required surgical intervention. Despite having surgery the patient continues having difficulty with ambulation and performing activities of daily living (ADL). 

The patient's ambulation has been impaired due to the ulcers.  The UAS notes limitation of walking due to foot problems.  Pain is noted as daily.  Gait speed is slow (as per UAS, 24 sec for timed 4 meter walk).  The patient is dependent on caregiver help for household tasks and all activities outside the home (shopping, errands, transportation).  At home, the patient needed limited assistance for walking in the mid-2019 UAS.  The physician noted there are still issues with ambulation after surgery during the healing process.  Because there is no updated medical information and the most recent available UAS is from 7 months ago, the level of assistance the patient currently needs is not known. However, some impressions can be drawn from the available information.

Considering the patient has history of chronic venous ulcers, recently had surgery on his foot, and the external appeal request for increase of CDPAS hours was submitted in late 2019, it is reasonable to consider that the patient still needs assistance for IADLs and ADLs.  The UAS-ATSP Summary of Hours Recommended from the middle of 2019 includes time allocated for all IADLs and most ADLs.  Time is allocated for toilet use and transfer toilet 6 times per day; 5 minutes for each transfer toilet and 5 minutes for each toilet use.  The same allocation of time is noted for indoor locomotion; 6 times per day, 5 minutes for each walk. There is a problem with this calculation.  Some IADLs and ADLs can be reasonably scheduled and completed within a specific timeframe. However, walking, transfers and toileting occur at various and often unpredictable times throughout the day; and the time needed may differ with each episode depending on how fast or slow the patient is moving; the distance he is walking; how much time he needs in the bathroom.  

With additional CDPAS hours, the patient will have help for ADLs and IADLs on Saturday; and a few additional hours the rest of the week will provide more time for assistance with walking, which can help the patient accomplish more tasks each day in his home, and/or have more time for outdoor errands by having the aide present to help him walk outdoors.  It also extends the hours that the patient can have assistance for toileting.  The patient is not requesting services for Sunday, so it appears that some assistance may be provided by an informal caregiver.  Assistance from informal caregivers is voluntary as per NYS regulations for personal care services (in this case, CDPAS).  Considering the patient is requesting additional CDPAS 10 hours per week, it is reasonable to conclude that he needs additional time for assistance with daily activities which cannot be provided by informal caregivers.

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 Consumer Directed Personal Care Assistance Services, Level ll, 34 hours per week is reversed.  The medical necessity is substantiated.