Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope, Hypertension.
Treatment: 60 hours (hrs) per week of the consumer directed personal assistance services.
The insurer denied 60 hours (hrs) per week of the consumer directed personal assistance services.
The determination is overturned.


This is a female patient with a history of syncope, hypertension, cerebrovascular disease, history of pulmonary emboli, hypothyroidism, arthritis, hyperlipidemia, and lymphoma. rected Personal Assistance Services (CDPAS). The patient and her care team requested 60 hours a week of CDPAS. The plan partially denied her request and approved 48 hours per week of CDPAS. The patient appealed this denial.
A video Uniform Assessment System (UAS) was completed. The patient was assessed at total dependence for the tasks of meal preparation, ordinary housework, managing finances, managing medications, stairs, and shopping; maximal assistance for tasks of phone use, transportation, bathing, dressing upper and lower body, and toilet use; extensive assistance for tasks of locomotion and transfer toilet; limited assistance for task of bed mobility; and independent for personal hygiene and eating. A tasking tool was used to determine that she requires 34.31 hours of aide service per week.
The patient's primary care physician (PCP) states that she is bed and wheelchair-bound and completely disabled. Her PCP states that she needs assistance with activities of daily living (ADLs) such as toileting, showering, dressing, diaper changes, moving in and out of bed, using her wheelchair and walker, cooking, feeding, and housework.
At issue is the medical necessity of 60 hours (hrs) per week of the consumer directed personal assistance services.

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, 60 hours per week of Consumer Directed Personal Assistance Services (CDPAS) is medically necessary.
There is documentation in the UAS of the patient requiring at least extensive assistance with the tasks of locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan did not document a plan to meet these unscheduled and unpredictable care needs. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. There is documentation from the patient's PCP of medical necessity of increased CDPAS to assist with ADLs of toileting and using her wheelchair and walker.
The patient lives with her son and therefore has informal support. However, per New York Codes, Rules and Regulations (NYCRR) 505.14, the plan cannot assume that the informal support person can provide all needed care outside of the approved CDPAS hours as informal supports must be voluntary. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS is not solely for safety and supervision but to assist the patient with activities of daily living (ADLs).