Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Disease; Diabetes; Cognition problems

Treatment: Consumer Directed Personal Care Assistance Services (CDPAS) of 24 hours per day, 7 days per week (split-shifts), for a total of 168 hours per week

The insurer denied coverage for Consumer Directed Personal Care Assistance Services (CDPAS) of 24 hours per day, 7 days per week (split-shifts), for a total of 168 hours per week.

The denial is overturned. 

This female patient has a past medical history of hypertension, deep vein thrombosis, peripheral vascular disease status post lower extremity stents, diabetes mellitus, gastroesophageal reflux disease, mild aortic stenosis, coronary artery disease, myocardial infarction, congestive heart failure, arthritis, shortness of breath and cognition and memory problems. A New York State Department of Health's Uniform Assessment System (UAS-NY) notes that the patient is residing at a skilled nursing facility (SNF) for rehabilitation after a recent hospitalization for heart problems and COVID-19. When she is discharged, she will live alone in an elevator building with a handicap entrance. Her grand daughter has stated that she visits the patient 1 to 2 times a month, but she is unable to assist with the activities of daily living (ADLs) and instrumental activities of daily living (IADLs) as she has a full time job. The patient has short term and procedural memory problems, and there is a notable decline over a 90 day period. The patient is alert and able to make her basic needs known, but she is forgetful and not self-directing. The patient wears hearing aids and is legally blind. The patient is unable to manage an emergency plan and personal emergency response system; she is totally dependent for meal preparation, ordinary housework, managing finances, locomotion and managing stairs. The patient uses a wheelchair and scooter for locomotion indoors. She is unable to walk on her own. The patient needs maximum assistance with bathing, dressing her lower body, walking, toilet transfer, toilet use and managing medications. She is frequently bladder incontinent, but is bowel continent and uses incontinence supplies, as needed. She needs extensive assistance with dressing her upper body. The patient needs limited assistance with personal hygiene, bed mobility and eating. The patient has intermittent pain with mild intensity, and her pain is controlled with therapeutics. She does have foot problems and has regular check-ups by Podiatry. 

The patient was previously receiving 11 hours per day of services. At issue is the need for 24-hour split shift aides. The insurer has denied the change, on the basis that the services needed were for supervision. At the SNF a Braden score was 9-12, noting a high risk for pressure sores. A every 2 hour turning and positioning program was begun. The patient is incontinent of urine, needs full assistance with transfer and toileting and cannot walk. The use of a diaper does cut down on the need for bed cleaning but still leaves the patient potentially lying in a wet diaper for hours. Her need for toileting is not scheduled. She has no predictable informal care. Her nighttime needs are not supervisory only. Five hours uninterrupted sleep would not be guaranteed.

The patient has scheduled medication BID (twice daily), Blood Sugar test QD (daily), and uses oxygen as needed. The provision for these services does not automatically require an SNF. The documentation provided for review supports a 24-hour split shift aide.

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

The medical necessity is substantiated. The health plan's denial of the request for the Consumer Directed Personal Care Assistance Services (CDPAS) of 24 hours per day, 7 days per week (split-shifts), for a total of 168 hours per week is overturned.