Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis and dementia

Treatment: Consumer Directed Assistance Program (CDPAP): 12 hours per day-7 days a week; 12 hours per day-7 days a week- a total of 168 hours per week (split shift)

The insurer denied coverage for Consumer Directed Assistance Program (CDPAP): 12 hours per day-7 days a week; 12 hours per day-7 days a week- a total of 168 hours per week (split shift). The denial was reversed.

This patient is a female who lives alone in apartment. Her daughter is the primary informal caregiver. The patient's diagnoses include osteoarthritis and dementia. As the patient's functional status declined over time, most likely both medical conditions were significant contributing factors; i.e. physical disability from pain, stiffness, decreased range of motion from arthritis, and cognitive impairment from dementia.  The UAS indicates high level of assistance is required for IADLs and ADLs. As per comments reported by the daughter, the patient does not appear to be able to engage in any purposeful participation in her daily activities due to her mental status.

There is limited information of the patient's medical condition over the past few years, but in a UAS from late-2018 it was noted that the patient had moderate pain at times. The mid-2019 UAS does not report pain, which may be due to decrease in activities that precipitated pain such as walking (patient is currently non-ambulatory). The mid-2019 includes reference to decreased ROM which is probably due to arthritis. With diagnosis of osteoarthritis it is reasonable to consider that the patient had symptoms from arthritis that affected her ability to perform daily activities even before her cognitive decline reached an advanced stage. Arthritis is a frequent cause of disability in older people and often results in loss of independence with routine daily activities.

It appears that currently the patient's severely impaired cognitive function is the primary cause of her dependence on caregiver assistance for all IADLs and ADLs. For a person with dementia, loss of ability to perform daily activities is an expected consequence of the disease. It is evident that a person at this stage of cognitive impairment and physical dependence on others for all daily activities cannot be left alone safely. There are safety concerns regarding the patient's ability to report an emergency if she is alone, e.g. it is highly unlikely that the patient can effectively use a PERS or the phone in case of emergency. However, the patient's need for 24 hour care is not only for safety supervision, or in case of an emergency. The patient requires ADL care throughout the day and night. The patient is completely incontinent and cannot provide self-care for incontinence. In addition, she needs maximal assistance for bed mobility. This creates a high risk situation for incontinence associated skin injury and pressure ulcers.

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services (in this case CDPAP). The patient is currently approved for CDPAP 10 hours per day x 7 days per week. Considering the daughter is requesting 24 hour care as two 12 hour split shift, it is reasonable to conclude that the daughter cannot provide the care her mother needs as a voluntary caregiver. There are no other informal caregivers identified in the records provided for review. 

Consumer Directed Personal Assistance Program services, 12 hours per day, 7 days per week; 12 hours per day, 7 days per week - total of 168 hours per week (split shift) is medically necessary. The health plan did not act reasonably in the best interest of the patient.

Based on the above, the medical necessity for Consumer Directed Assistance Program (CDPAP): 12 hours per day-7 days a week; 12 hours per day-7 days a week- a total of 168 hours per week (split shift) is substantiated.  The insurer's denial is reversed.