Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, aphasia, obstructive sleep apnea (OSA), osteoarthritis.
Treatment: Consumer Directed Personal Assistance Services to hours per week.
The insurer denied coverage for the Consumer Directed Personal Assistance Services to hours per week.
The denial is overturned.

This male patient has substantial functional impairment, requiring assistance for all daily activities. The patient lives alone. The UAS (Uniform Assessment System) indicates the patient has one informal helper (friend) who provides some assistance with Instrumental Activities of Daily Living (IADLs). The patient primarily depends on personal care services for assistance with Activities of Daily Living (ADLs) and IADLs. Services are provided through CDPAS (Consumer Directed Personal Assistance Services). Prior to eligibility for managed long-term care (MLTC) plan, the patient was receiving 24-hour private care at home. MLTC plan approved CDPAS 91 hours per week, live-in services. The patient's friend (patient designee) requested an increase of CDPAS to 168 hours per week, which was denied. An external appeal was requested. 

The most recent Uniform Assessment System (UAS) provided was reviewed. A functional status report indicates the patient is totally dependent for all IADLs. For ADLs, the patient needs maximal assistance bathing, personal hygiene, dressing upper/lower body, toilet use, eating, limited assistance for walking, locomotion, transferring to the toilet, and bed mobility.

The patient has a diagnosis of dementia. The patient's friend reported the patient was diagnosed with Alzheimer's dementia (AD). The UAS includes a diagnosis of primary progressive aphasia (reported in section B cognition/comments). Primary progressive aphasia (PPA) is a variant of frontotemporal dementia that affects language and ability to communicate (friend reported patient lost the ability to speak 4-5 years ago). There are no neurology records available for review regarding these diagnoses. The earlier stages of AD and PPA have features that distinguish each from the other, but as each disease progresses to late stage, cognitive, behavioral and language problems are often present in both. 

As per the UAS, the patient has one informal helper (friend) who assists with some IADLs. As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services (in this case, CDPAS) are indicated to assist with ADLs and IADLs when needed during the day and night. The patient needs help for routine IADLs and ADLs; and for ADLs that occur at unscheduled and recurring times of the day and night. The patient's daily care needs do not appear compatible with the schedule of a live-in aide, which includes 5 uninterrupted hours of sleep per day (plus 3 more hours of sleep during the day or night). 
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the consumer directed personal assistance services (CDPAS) 168 hours per week is overturned. Medical Necessity is substantiated.