Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Home Health Care. 
The insurer denied CDPAS. 
The health plan's determination is overturned in whole. 

The patient is old female with a past medical history of obstructive sleep apnea, anemia, diabetes mellitus type 2, hypertension, and asthma whose physician filed a M-11 Q form for personal care services/Consumer Directed Personal Assistance Services (CDPAS). The patient's provider noted the patient needs monitoring especially during sleep apnea events and episodes and asthma attacks. The provider stated, "patient needs a home health aide and night time care is necessary as her apnea attacks and asthmatic attacks occur at night". 

The patient had an assessment tool performed assessing the patient at maximal assistance for task of ordinary housework while extensive assistance with shopping. The patient was assessed at limited assistance for tasks of stairs, transportation, and equipment management while independent with tasks of managing finances, managing medication, phone use, bathing, personal hygiene, dressing upper body/lower body, locomotion, transfer toilet, toilet use, bed mobility, and eating. 
The subject under review is the medical necessity for the requested services.

The requested Consumer Directed Personal Assistance Services are medically necessary for this patient. The patient had an assessment tool performed noting the patient required maximal assistance with ordinary housework and extensive assistance with shopping. Per New York Codes, Rules and Regulations (NYCRR) 505.28 the assessment for home-based services identifies the tasks necessary to keep the enrollee safely in the home. The plan of care is developed by the patient with the assistance of the insurer, provider and any individuals the enrollee chooses to include.
The plan of care is developed in conjunction with the patient based on the assessment and considers the number of hours authorized to accomplish the tasks. These tasks may include level 1 and level 2 personal care services (PCS), home health aide services and/or skilled nursing tasks.
The insurer must authorize only the hours or frequency of services that the enrollee actually requires to maintain the enrollee s health and safety in the home. The hours or frequency of services must also include receipt of services received outside of the home. CDPAS are managed by the patient in accordance with the enrollee's plan of care. The authorization should provide the number of hours authorized however; it is the enrollee who decides how those hours are arranged over the week. The insurer does maintain the right to determine whether the number of hours is appropriate to the plan of care. As in the personal care services benefit, authorization for housekeeping-only tasks are limited to eight (8) hours per week. This patient's task based assessment tool estimated 11.48 hours/week. The patient also needs assistance with administration of nebulized medication. Consumer Directed Personal Assistance Program (CDPAP) aides may perform "skilled tasks" unlike regular personal care aides. Another special benefit of CDPAP is that CDPAP aides may perform "skilled" care that otherwise may only be performed by a nurse - suctioning tracheostomies, insulin injections, administration of oxygen or medications where the consumer cannot self-administer. Tasks that could not otherwise be performed by home health aides or personal care aides are indicated in the scope of tasks for personal care and home health aides.