Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, gastroesophageal reflux disease without esophagitis, mixed irritable bowel syndrome, neuralgia and neuritis

Treatment consumer directed personal assistance (CDPAS) services of 49 hours per week

The insurer denied coverage for CDPAS services of 49 hours per week	

The denial is overturned

The patient is an adult female with a past medical history of right breast cancer, hypertension, gastroesophageal reflux disease without esophagitis, mixed irritable bowel syndrome, neuralgia and neuritis, abnormalities of gait and mobility, seasonal allergic rhinitis, depression, overactive bladder, unspecified joint pain, pruritus, vitamin D deficiency and wheezing. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient lives with her husband and daughter in a private home. She needs assistance with her activities of daily living and instrumental activities of daily living due to her diagnosis of right breast cancer. She had a mastectomy and recently had a biopsy to her left arm. The patient is experiencing body weakness and limited range of motion.

She is totally dependent for ordinary housework. The patient needs maximum assistance with meal preparation and shopping. She needs extensive assistance with managing finances, managing stairs, transportation, equipment management, bathing, dressing her upper and lower body, toilet transfer and toilet use. The patient needs limited assistance with managing medications, personal hygiene, walking, bed mobility, eating and locomotion. She uses a cane as an assistive device for locomotion indoors. The patient is frequently bladder incontinent but has complete bowel control. She uses pull ups for her incontinence.
 
The patient reported having a fall while taking a shower. There was no medical intervention during this incident.  She needs setup help only with phone use. 

An increase to consumer directed personal assistance (CDPAS) services of 49 hours per week is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 

(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The patient is a woman with impairments as noted above. She lives with her husband who is himself in poor health. She also lives with her daughter who provides some informal care. The patient is alone for at least 2 hours/day. The assessment of her needs was done, based on prior UAS. The Final Determination was done. The UAS shows an increase in her needs compared prior UAS, e.g. transfers and toilet use are now extensive assistance as opposed to limited. There is documentation that her needs have increased, and the increase in hours is approved.  

The healthcare plan did not act reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance (CDPAS) Services of 49 hours per week is reversed. Medical necessity is substantiated.