Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Right hip fracture, Dementia
Treatment: Consumer Directed Personal Assistance Services (CDPAS), 84 hours per week
The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS), 84 hours per week.
The denial is overturned. 

This is a female patient with a medical history of dementia, anxiety, coronary artery disease (CAD), heart failure (HF), atrial fibrillation (A-fib), macular degeneration, osteoarthritis (OA), unsteadiness, weakness, wandering and falls with recent right hip fracture; status post open reduction internal fixation (ORIF). The patient lives alone. Her son lives next door. The patient has been approved for Consumer Directed Personal Assistance Services (CDPAS) 54 hours per week. The son assists when he can, but is limited due to his work. It was noted in outpatient medical records that he pays for additional aide hours. The son requested increase of CDPAS to 84 hours per week which was denied. 

The Uniform Assessment System (UAS), was done shortly after patient returned home from the hospital status post (s/p) fall and ORIF right hip fracture. At that time she was receiving Physical Therapy (PT) at home. At the time of the UAS report, the patient was totally dependent in most instrumental activities of daily living (IADLs), except medications and phone use (maximal assistance). For activities of daily living (ADLs), the patient needed extensive assistance for bathing, lower body dressing, walking, transfer toilet/toilet use; limited assistance for personal hygiene, upper body dressing and eating. Bed mobility was noted as setup help. 

Considering the patient's functional status and symptoms noted in the UAS (shortly after right hip ORIF), and what is reported as progressive functional decline in the following 2 months (as per outpatient records), it is apparent that the patient needs assistance for all daily activities. Therefore, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day and night to provide assistance for all daily activities. This is not for companionship or stand-alone safety supervision. The patient needs assistance for daily activities that occur at various scheduled and unscheduled times throughout the day and night. Without adequate assistance, the patient is at risk for significant adverse events, including falls/injuries, malnutrition, aspiration, skin injury. Providing assistance is also needed to improve the patient's comfort. The effort to provide self-help when she is alone is stressful and can increase the patient's physical discomfort, anxiety and behavioral problems associated with dementia.

The only informal caregiver identified in the available records is the patient's son. It was noted that he provides some assistance, but due to his work schedule he is unable to assist on a regular basis. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services; this includes direct care from informal caregivers, and from paid caregivers at the expense of informal caregivers. The patient needs assistance with ADLs at various times over 24 hours each day. The patient is at risk for harm if she does not have caregiver assistance for ADLs when needed throughout the day and night. The number of CDPAS hours that can be approved from this review is limited by the number of hours requested, in this case, 84 hours per week. 

The insurer did not act reasonably, or with sound medical judgement, or in the patient's best interest.

The carrier's denial of coverage for CDPAS, 84 hours per week is overturned. The medical necessity is substantiated.