Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Diabetes, Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome.
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours.

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours.  The denial is overturned.

This patient has extensive medical history associated with functional impairment. He was recently admitted to the hospital for treatment of lymphoma. As per the UAS (Uniform Assessment System) and progress notes from the oncologist, the patient experienced various post-treatment adverse effects resulting in physical and cognitive decline. Prior to hospitalization, the patient needed help with daily activities and was receiving personal care services as Consumer Directed Personal Assistance Services (CDPAS) 12 hours per day, 7 days per week. His daughter-in-law is the CDPAS aide. The patient lives with his wife, who was providing some informal care as reported UAS. After the recent hospitalization, the patient's functional status declined further. It was noted in the UAS that the wife has health problems and can only provide assistance as tolerated. As per the UAS, the patient's son temporarily left work to care for his father; so, the son has been providing care during the day, and the daughter-in-law (CDPAS aide) provides care at night. The physician's letter indicated the son needs to return to work, so request was made to increase CDPAS to 24 hours per day split shift, which was denied. An external appeal was requested.
 
The patient has frequent urinary incontinence which may be at least partly due to his poor mobility, and difficulty reaching the toilet in time (i.e., functional incontinence). The insurer's final denial letter recommended limiting fluids after 6 p.m. to decrease nighttime urination. The oncologist strongly advised the patient to drink 2L (liter) of fluid per day. It may be difficult for the patient to drink 2L of fluid between morning and 6 p.m., so stopping fluids after 6pm is probably not a realistic plan. The daughter-in-law (CDPAS aide) and son have managed all the patient's toileting and incontinence care needs. 

With all the considerations noted above, it is medically necessary and in the patient's best interest at this time to have caregiver assistance available throughout the day and night, i.e., 24-hour split shift services. The prudent course of action is to provide additional personal care service hours to ensure the patient has necessary caregiver support for all daily activities, including all routine IADLs (instrumental activity of daily living) (e.g., meal preparation/service, medications, household related tasks), routine ADLs (Activities of daily living) (morning/evening: bathing, personal hygiene, dressing; and mealtime assist with eating), and ADLs that occur at unscheduled and recurring times of the day and night (including walking, transfers, toileting, incontinence care, bed mobility). 

Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. It cannot be assumed that family member(s) can provide informal care during non-CDPAS hours. The patient's wife and son are unable to consistently provide care to the patient for extended periods of time each day. The daughter-in-law provides care as CDPAS 12 hours per day, and her availability to provide additional care is not known and cannot be assumed. Therefore, there are no clear options for informal care during non-CDPAS hours. CDPAS hours are flexible, but when the person receiving care has frequent unscheduled care needs, the CDPAS aide must be available at all times of the shift. 

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 Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours is overturned. Medical Necessity is substantiated.