Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cerebrovascular accident (CVA). 
Treatment:  Consumer and Self-Directed Personal Assistance Service to 84 Hours per Week

The insurer denied Consumer and Self-Directed Personal Assistance Service to 84 Hours per Week.  The denial is overturned.

The patient is an adult male with a primary diagnosis of right (dominant side) hemiplegia (G81.91) from a cerebrovascular accident (CVA) involving the left internal carotid artery (ICA). 

His other listed medical conditions include aphasia following cerebral infarction, I69.320; essential (primary) hypertension, I10; hyperlipidemia, unspecified, E78.5; major depressive disorder, recurrent, F33.9; need for assistance with personal care, Z74.1; other abnormalities of gait and mobility diagnosis present, R26.89; other fatigue, R53.83; other muscle spasm, M62.838; and stress incontinence, N39.3. Two months ago, the Uniform Assessment System Report indicates:
1. The patient remains alert and oriented times three (AOX3) with intermittent forgetfulness. The patient remains able to make his needs known. The patient is able to call 911 in an emergency. 
The patient continues to have his spouse and daughter assist him on a daily basis.
2. The patient has and uses his glasses. Normal tone and level were spoken with the patient and spouse today. The patient has aphasia and some difficulty in expressing himself was noted.
3. The patient has a diagnosis of depression that is managed with medication. The patient does not see a psychiatrist or therapist at this time. Medication for depression is managed by his primary care physician.
4. The Significant Change in Condition (SCIC) assessment is done due to a request for a change of service. The patient's spouse is reporting the patient has had a decline in functional status for the past two to three months due to residual effects of cerebrovascular accident (CVA). The patient needs ongoing assistance and care with all aspects of instrumental activities of daily living (IADLs) and activities of daily living (ADLs). The patient has hemiplegia due to cerebrovascular accident. The patient remains in need of assistance with all transfers as he cannot lift his leg to get into bed or get dressed. He remains unsteady with his gait including with the use of a quad cane and contact guarding. The patient is unable to dress himself or button/zip clothes. The patient is unable to safely get into the shower without assistance, he needs help with washing areas hard to reach, he is unable to perform personal hygiene without assistance, shaving, and brushing teeth. Durable medical equipment (DME) includes cane, shower chair, grab bars, and pullup. The caregiver reports that the patient has ongoing occasional incontinence of the bladder due to reduced mobility. The patient wears pull-ups daily. The patient remains unable to change products himself or to cleanse himself after toileting.
5. The patient remains unable to open bottles or take his medications independently. The patient needs assistance with putting medications in his mouth and assisting with drinking liquids to swallow, due to hemiplegia on the right side.
The Plan found your needs can be met with Consumer and Self-Directed Personal Assistance Service (CDPAS) 56 hours per week. You have Consumer and Self-Directed Personal Assistance Service (CDPAS) services that provide flexible hours throughout the day. The Plan wrote a letter stating "Based on these tools, assessments and the NYSDOH Guidelines, Title: section 505.28 Consumer Directed Personal Assistance Services 
(CDPAS), your appeal is upheld because it is not medically necessary for you to receive 84 hours per week of CDPAS to assist with your activities and maintain your health within the home."

The requested health service is medically necessary.

The Plan letter alluded to the ability to ambulate with an assistive device and the referral for physical therapy to improve strength and other functions. In the same evaluation, the patient reported during telehealth that he needs "help all the time". A review of the report also indicates extensive to maximal assistance needed in performing activities of daily living. The report also noted moderate fatigue and an inability to finish normal day-to-day activities. It noted that the consumer-directed personal assistant's total minutes in the last week was 5040. As such, the available records for review do not support that the patient's clinical status has improved to warrant less than 84 hours per week. Therefore, the requested health service is medically necessary.