Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Muscle weakness, Normal pressure hydrocephalus, Peripheral arterial occlusive disease

Treatment: Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day; 84 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day; 84 hours per week.

The denial is overturned. 

This is a female with a medical history of uncontrolled Type ll diabetes mellitus, aortic valve disorder, peripheral arterial occlusive disease, muscle weakness, congestive heart failure, sepsis, diabetic polyneuropathy, chronic obstructive lung disease, chronic kidney disease stage 3, cerebrovascular accident, anemia, migraine and normal pressure hydrocephalus. She has been receiving Consumer Directed Personal Assistance Service (CDPAS) 35 hours per week. The patient requested an increase of CDPAS to 84 hours per week, which was denied by the insurer. 

Uniform Assessment System (UAS) documentation indicates that the patient is totally dependent for housekeeping tasks; needs maximal assistance for meal preparation and shopping; extensive assistance for stairs and medications. For activities of daily living (ADLs), the patient needs extensive assistance for bathing and dressing and limited assistance for all other ADLs, except bed mobility (setup help). The UAS indicates the patient's decision making for daily tasks is modified independence (some difficulty in new situations). The patient needs extensive assistance with finances and medications, which can suggest some cognitive deficits. Overall, it does not appear that cognitive impairment is a major contributing factor to the patient's functional impairment with most daily tasks. The patient's physical limitations are most likely the primary cause of the patient's need for assistance with most daily activities.

This patient has an extensive medical history associated with various symptoms causing decreased functional ability with daily activities Considering the patient's medical conditions and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day to provide assistance with household related tasks and ADLs. The patient's daughter was able to provide assistance; however, the daughter is currently working and unable to continue providing informal care. The UAS identified a second informal caregiver. There is no current information on the availability of the other caregiver. Considering the request for additional service is for 84 CDPAS hours per week, it is reasonable to conclude that there are no informal caregivers who can provide care for that amount of hours per week. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. When informal caregivers are unavailable for personal care assistance on a regular basis, then personal care services are indicated to provide necessary assistance with daily activities as needed throughout the day. 

CDPAS 12 hours per day can adequately accommodate all instrumental activities of daily living (IADLs) and ADLs that are done on a routine basis each day.  However, the patient needs assistance with toileting, incontinence care and mobility around her home (transfers, walking). It is unclear how the patient will have assistance for these unscheduled activities when they occur at times when the aide is not present. It is not known whether there is a plan for informal caregivers to provide assistance when the aide is not present. Re-assessment will determine if further modification of the plan is needed to meet the patient's personal care needs.

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

Based on the above, the medical necessity for CDPAS, 7 days per week, 12 hours per day; 84 hours per week is substantiated. The insurer's denial is overturned.