Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impaired cognitive status.
Treatment: Increase in Consumer Directed Personal Assistance Services (CDPAS) from 7 days per week, 24 hours per day, live in to 7 days per week, 24 hours per day, continuous care by more than one person. 
The insurer denied an increase in Consumer Directed Personal Assistance Services (CDPAS) from 7 days per week, 24 hours per day, live in to 7 days per week, 24 hours per day, continuous care by more than one person. 
The determination is overturned.

The patient has a past medical history of cognitive impairment, bladder incontinence, bowel incontinence, hypothyroidism, osteoarthritis, hyperlipidemia, congestive heart failure, cerebrovascular accident (CVA), hypertension, oxygen (O2) requirement, urinary tract infection (UTI), hemiplegia, atrial fibrillation, hand contractures, glaucoma, and hearing loss who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 24 hours/day, live-in, 7 days per week. The patient had a house call visit stating the patient should have repositioning every 2 hours to relieve pressure points, and to minimize skin injury caused by friction or shearing. The patient was seen again by a house call physician again recommending repositioning every 2 hours to relieve pressure points and minimize skin injury caused by friction or shearing.
The patient had a telemedicine visit with her provider with a review of pressure ulcer prevention. The patient was seen again via telemedicine. An office note stated the patient was dependent on a caregiver for bathing, dressing, eating, transferring, toileting, and incontinence care of bowel and bladder. A letter also stated the patient was oxygen dependent, bedbound, nonverbal, and required total assistance with all activities of daily living. In addition, the letter stated the current schedule of home health aides was not adequate for the patient's level of care due to the need for constant monitoring to ensure comfort and safety.
The patient underwent a telephonic assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, phone use, stairs, shopping, transportation, equipment management, bathing, personal hygiene, dressing upper/lower body, toilet use, and bed mobility while maximum assistance with tasks of managing medication and eating. The tasks of walking, locomotion, and transfer toilet did not occur and there was no estimated care need level assigned for these tasks.
The insurer sent a final adverse determination denial notice regarding the request to increase CDPAP service hours noting the request was not medically necessary and the patient did not meet criteria. The insurer felt the current authorized level of CDPAP services was sufficient to meet the patient's activities of daily living (ADLs) and nighttime needs. The letter further stated the patient was receiving skilled services from New York hospice program at home. The letter also stated there were no follow-up visits with the patient's medical provider and a follow-up was recommended.
At issue is the medical necessity of an increase in Consumer Directed Personal Assistance Services (CDPAS) from 7 days per week, 24 hours per day, live in to 7 days per week, 24 hours per day, continuous care by more than one person. 

The services are medically necessary.
The patient has documented progression of chronic medical conditions including cognitive impairment, osteoarthritis, and heart failure and has documented worsening cognitive and functional status. The patient's primary care provider recommended turning and repositioning every 2 hours to prevent skin breakdown and ulceration. The patient was noted to be homebound, bedbound, and hemiplegic. The patient was also placed on oxygen with the initiation of hospice. The patient requires at least maximum assistance with all ADLs/ instrumental activities of daily living (IADLs). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer did not document a plan to meet these unpredictable and unscheduled care needs. The current CDPAP hours and/or adaptive equipment and/or medical supplies are not sufficient to meet the patient's ADL/IADL care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient does not need routine follow up appointments with her physician as she is on hospice. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 24 hours/day, continuous, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.