Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bipolar depression; Diabetes mellitus.
Treatment:  Increase in Consumer Direct Personal Aide Service (CDPAS) to 7 days x 9 hours.

The insurer denied coverage for increase in Consumer Direct Personal Aide Service (CDPAS) to 7 days x 9 hours.  The denial is overturned.

This male patient has a history of anxiety, bipolar disorder, depression, coronary heart disease, diabetes mellitus, osteoarthritis, spinal stenosis, hypertension and hyperlipidemia.  Per a Uniform Assessment System (UAS), the patient lives alone in a 1-bedroom apartment and currently receives Consumer Direct Personal Aide Service (CDPAS) 7 days per week x 6 hours per day.  He is able to verbalize his needs and can dial 911 in an emergency.  The patient requires maximal assistance for meal preparation, housework, stairs, and transportation.  He requires extensive assistance for managing finances, managing medications, shopping, bathing, and dressing lower body.  He needs limited assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility.  The patient ambulates with a cane and hands-on support while inside and uses a rollator when outside.  He is occasionally incontinent of bladder.  He has chronic joint pain and stiffness, sciatica, low back pain, and numbness.  He has moderate fatigue and is unable to finish normal day-to-day activities.  The patient's daughter pre-pours his medications, and he requires daily reminders.  

The patient needs assistance with toileting, hygiene, and clothing.  The daughter reported the patient is unable to change his diaper without assistance.  Considering the patient has very slow, unsteady gait, the frequency of incontinence may increase due to delay in reaching the toilet in time.  The patient also needs maximal assistance with bathing and dressing, which may be necessary more frequently due to incontinence.  If he cannot manage proper self-care with toileting and incontinence, he must wait until the aide returns the next day.  This can result in incontinence associated skin damage (e.g. dermatitis, fungal infection).  Other concerns include evening ADLs, such as dinner, change of clothes, personal hygiene, toileting, and transfer into bed. 

Considering the patient's medical history, with associated symptoms and functional limitations, it is medically necessary for the patient to have caregiver assistance with IADLs and ADLs for at least most of the daytime to early evening hours when the patient is most active around his home and needs to complete routine daily tasks.  The UAS identified 2 informal caregivers that call daily and visit a few times per week; however, the UAS did not indicate that either was available to provide daily assistance with ADLs after the aide leaves each day.  

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  Without informal caregivers, who can provide consistent help with daily activities when needed each day, personal care services are indicated to provide assistance with IADLs and ADLs when needed throughout the day.  For this patient, personal care services 42 hours per week may be sufficient to provide assistance with IADLs, and some ADLs during a limited number of hours per day.  However, this amount of personal care service does not provide sufficient time for the patient's ADL needs that extend beyond 6 hours per day, including assistance with transfers, walking, toileting, incontinence care, and evening ADLs. 

Consumer Direct Personal Aide Service 7 days x 9 hours is medically necessary.  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 the requested increase in CDPAS to 7 days x 9 hours is overturned.  The medical necessity is substantiated.