Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar radiculopathy, bilateral primary osteoarthritis of the knees
Treatment: Consumer Directed Personal Assistance Services (CDPAS) of 3 hours per day, 7 days per week in addition to the current schedule, for a total of 63 hours per week

The insurer denied coverage for CDPAS of 3 hours per day, 7 days per week in addition to the current schedule, for a total of 63 hours per week.  The denial is overturned.

The patient is woman with a past medical history of lumbar radiculopathy, bilateral primary osteoarthritis of the knees, dementia, hypertension, asthma, multiple joint pain, and gastroesophageal reflux disease (GERD). Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, her daughter and son-in-law were present on the call. The patient lives in a second floor apartment of a private home with her daughter, son-in-law and grandchild. There are 15 steps to access the apartment. The patient's activities of daily living (ADL) status has declined compared to before. Her overall self-sufficiency status has also deteriorated compared to before. She requires assistance with her instrumental activities of daily living (IADLs) and activities of daily living (ADLs) due to her decreased cognition related to dementia and decreased range of motion (ROM) and pain related to osteoarthritis. Per the patient's daughter, the patient had a fall within the past week due to dizziness, and she had some bruises. The patient's daughter denied calling the police or taking the patient to the Emergency Room (ER).

Needs are:  1) Total dependence for meal preparation, ordinary housework and shopping; 2) Maximal assistance for managing finances, managing medications and stairs; 3) Extensive Assistance for phone use, transportation, equipment management, bathing, personal hygiene, dressing upper and lower body, walking, locomotion, toilet transfer and toilet use; 4) Limited assistance for bed mobility and eating; 5) Cognition: There is impairment; 6) Continence: The patient is frequently bladder incontinent and occasionally bowel incontinent. She cannot clean herself. She uses incontinence supplies, but per the patient's daughter, the patient has a history of urinary tract infections (UTIs).

The patient uses an assistive device for locomotion indoors. 

An increase to Consumer Directed Personal Assistance Services (CDPAS) of 3 hours per day, 7 days per week in addition to the current schedule, for a total of 63 hours per week is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 

(a) Definitions and scope of services.

(1) 	Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

Due to dementia, urinary incontinence and physical impairments, the patient needs extensive-maximal assistance with all ADLS. She needs multiple changes in pull-ups that she cannot do herself. She has a history of UTIs. 

The provision of diapers and alternate pressure beds is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers"- changing diapers regularly and positioning are also necessary. 

The patient's needs are not just for safety or supervision. The increase in hours is approved.  
	
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plans assessment of the patient's needs.

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 3 hours per day, 7 days per week in addition to the current schedule, for a total of 63 hours per week is reversed. Medical necessity is substantiated.