Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe cognitive impairment and physical/sensory impairments.

Treatment: Consumer Directed Personal Care Assistance Services (CDPAS) of 84 hours per week.

The insurer denied coverage for CDPAS of 84 hours per week.

The denial is overturned. 

This is a female patient who has intellectual disability with severe cognitive impairment. She was approved for Consumer Directed Personal Assistance Services (CDPAS) 35 hours per week. A request was made for an increase to 84 hours per week, which was denied by the insurer; but CDPAS was increased to 56 hours per week. 

Uniform Assessment System (UAS) system documentation was provided for review. The UAS indicates the patient is totally dependent for most instrumental activities of daily living (IADLs) (housework, meal preparation, shopping, finances, phone use); except: medications, transportation (maximal assistance); stairs (extensive assistance). The patient needs extensive assistance for all activities of daily living (ADLs); except bed mobility (independent).  There is no formal evaluation of the patient's cognition provided for review, but the UAS includes description of various aspects of the patient's cognitive ability. Decision making for daily activities is severely impaired; she has short term and procedural memory impairment. She is easily distracted. Communication is very limited; it is noted the patient is nonverbal; she is unable to make her needs known. Her comprehension is very limited, and may be exacerbated by her bilateral hearing loss. It is noted that the family anticipates her needs. As per the mother's letter, the patient displays disruptive behavior. She appears to have very limited or no safety awareness.

As a result of severe cognitive impairment and physical/sensory impairments, the patient needs assistance for all IADLs and most ADLs (except bed mobility as per UAS), including ADLs that occur at various and unscheduled times of the day and night. Therefore, it is medically necessary for the patient to have a caregiver present and available to provide assistance with all daily activities, including ADLs that occur at unscheduled times throughout the day and night. The request for additional services is for CDPAS 84 hours per week, 12 hours per day. The patient is currently approved for CDPAS 56 hours per week, 8 hours per day; so the request is for an additional 4 hours per day. The insurer noted in their final denial letter that personal care services through CDPAS offer flexibility and allows scheduling of the personal assistant throughout the day and week that best suits the patient's needs. Therefore, the use of 12 hours per day does not need to be 12 consecutive hours. The patient has ADL needs throughout the day, including routine care in the morning, afternoon and evening, and unscheduled ADL needs at various and unscheduled times of the day and night. The additional 4 hours per day will help cover periods of time needed for IADL and ADL assistance at various times of the day and night. 

CDPAS 12 hours per day may be a low estimate for the patient's total care needs over 24 hours, as she needs ADL care at various times through the day and night. 

Considering the family's commitment to provide informal care, and their unwillingness to have an aide in the house at night, then CDPAS 12 hours per day can cover a substantial part of the patient's IADL and ADL needs, with additional services provided as informal care. If the family decides to use personal care assistance (PCA) services for some or all of the approved hours, then the recommendation for 84 hours per week applies to CDPAS, or PCA or any combination of these services.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient

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