Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Huntington's disease and insomnia.
Treatment: CDPAP (Consumer Directed Personal Assistance Program) 12 hours per day- 7 days per week: 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.

The insurer denied coverage for CDPAP 12 hours per day- 7 days per week: 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.
The denial is overturned.

This female has Huntington's disease, late stage with severe functional impairment. She is dependent on caregivers for all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives alone and receives personal care services as Consumer Directed Personal Assistance Program (CDPAP) 84 hours per week. 

The patient is incontinent of bladder and bowel, noted in UAS (Uniform Assessment System) as no control present. The patient is bedbound. It is noted there is a Hoyer lift for transfers, but it appears patient is no longer transferred to a toilet or commode; and so, all elimination is managed as incontinence care. The patient receives tube feeding 20 hours per day and hourly water flush in prescribed amounts as recommended by a dietician (from the hospital and/or rehab facility), and so it is likely that bladder and bowel elimination occurs at multiple and various times during the day and night. Diapers are not the full solution to incontinence for a patient incapable of any type of self-help. Leaving the patient in soiled diapers for up to 12 hours is not consistent with medical and nursing standards for incontinence and skin care. Prolonged skin exposure to wet soiled diapers increases risk of incontinence associated skin damage (e.g., dermatitis, fungal infection) and increases risk of pressure ulcers. Incontinence can increase risk of urinary tract infection, especially with fecal incontinence. The patient needs a caregiver present throughout the day and night to ensure prompt attention to incontinence for the patient's health and comfort.

The patient is at high risk for pressure ulcers. She is totally dependent for bed mobility, and so she is unable to effectively reposition herself on a regular basis when she is in bed, which is currently where she spends most or all of her time. The patient's risk for pressure ulcer is also increased due to incontinence (another reason for ensuring prompt incontinence care). The patient was significantly underweight at the time of the UAS. Impaired nutrition is a risk factor for pressure ulcers. With tube feedings, her nutritional status may have improved, but nutritional risk may still be a concern. 

The available information provides substantial support for medical necessity for 24-hour continuous services (i.e., split shift). Live-in services would not be adequate, as the patient's care needs are not compatible with the schedule of a live-in aide, which includes 5 uninterrupted hours of sleep per day (within 8 total hours of sleep per day), as per NYS (New York State) regulations for live-in aides. As described in this report, the patient's frequent care needs could not be properly met by an aide who is unavailable for 5 continuous hours per day; therefore, 24-hour continuous personal care services (in this case CDPAP) are indicated.

Consumer Directed Personal Assistance Program services, 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (split shift) - total of 168 hours per week is medically necessary. 

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 Program (CDPAP) 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week is overturned. Medical Necessity is substantiated.