Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lewy Body Dementia

Treatment: Increase of CDPAP services to 33 hours per week, 5.5 hours per day, 6 days per week

The insurer denied coverage for increase of CDPAP services to 33 hours per week, 5.5 hours per day, 6 days per week

The denial is overturned

This patient has experienced functional decline associated with several medical conditions and needs help with all daily activities. The patient lives with their son in a private house. The patient receives personal care services through Consumer Directed Personal Assistance Program (CDPAP). The insurer approved CDPAP services 27 hours per week, 4.5 hours per day, 6 days per week. As per the Uniform Assessment System for New York (UAS), the son and the patient's sister provide informal help with daily activities (the patient's sister lives in an upstairs apartment of the house where the patient and their son live). The patient (via designee) requested an increase of CDPAP services to 33 hours per week, 5.5 hours per day, 6 days per week, which was denied. External appeal was requested.

The most recent UAS provided for review was completed. Functional status report for Instrumental Activities of Daily Living (IADLs) indicates the patient was totally dependent for ordinary housework and managing finances; needed maximal assistance for meal preparation, managing medications, shopping, transportation; needed extensive assistance for stairs; and needed limited assistance for phone use. For Activities of Daily Living (ADLs), the patient needed maximal assistance for bathing, personal hygiene, dressing upper/lower body, transfer toilet, toilet use, extensive assistance for walking, locomotion, bed mobility, and eating.
Comparison with prior UAS indicates functional decline for most ADLs.

Functional decline in the elderly is generally due to the effects of the person's medical conditions resulting in physical and/or cognitive impairment.  Other contributing factors include economic and social circumstances (e.g., caregiver support). 

The UAS and physician's office records report the patient has Lewy body dementia (LBD). LBD causes substantial functional disability. Compared to other types of dementia (e.g., Alzheimer's disease), LBD causes greater difficulty with motor function, earlier functional decline of ADLs, and earlier loss of independence. Other problems include visual hallucinations, depression, anxiety, fluctuations of cognition, sleep disturbances, fatigue, autonomic dysfunction, orthostatic hypotension. Parkinsonian symptoms are often present, including bradykinesia, tremor, rigidity, postural instability/impaired balance (which increases fall risk). Caregiver stress is common due to the high level of assistance the affected person needs for ADLs and IADLs due to physical and cognitive impairment, and behavioral and mood disorders associated with LBD. 

The patient is receiving CDPAP 27 hours per week. Based on the information provided for review, it does not appear the patient's care needs can be met with 27 hours of personal care services per week.  The patient needs help with all ADLs and IADLs which occur at multiple and various times from morning to evening; and some assistance is most likely needed at night, e.g., for toileting/incontinence care; repositioning for pressure and/or pain relief; and medication for pain as needed. CDPAP hours are flexible, but for a person who needs help with daily activities that require extended time and high level of physical effort multiple times over the course of the day and night.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for increased Consumer Directed Personal Assistance Program (CDPAP) services, for a total of 33 hours per week is substantiated.