Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular dementia, depression, Parkinson's disease, hearing loss, functional urinary incontinence, gastroesophageal reflux disease (GERD), hypothyroidism, hypercholesterolemia. 

Treatment: CDPAS (Consumer Directed Personal Assistance Services) for 70 hours per week. 

The insurer denied coverage for CDPAS for 70 hours per week. 

The denial is overturned. 

This female patient has significant functional impairment and needs substantial caregiver assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient also receives Consumer Directed Personal Assistance Services (CDPAS) 33 hours per week. Family requested increase of CDPAS to 70 hours per week, which was denied. External appeal was requested. 

The UAS (Uniform Assessment System) indicates advanced cognitive impairment. The patient's decision-making ability for daily tasks is consistently poor/unsafe and she needs cues/supervision at all times. She is disoriented and has extensive memory impairment. Communication is limited to concrete requests, and she responds only to simple direct communication. She has behavioral disturbances that includes verbal and physical aggressive behavior with caregivers. Neurologist reported patient is often awake at night. She has hallucinations. She has been treated with quetiapine; current efficacy is not known from available records. 

The UAS reported patient needs maximal assistance for toilet transfer and toilet use. It was noted she had occasional urinary incontinence. Considering the difficulty with mobility, it is not clear whether the patient is still brought to a toilet or commode on a regular basis. It is uncertain whether the patient is still able to inform a caregiver when she needs to use the toilet/commode. As dementia progresses, there is decreasing ability to recognize and remember the cues and procedures needed for toileting. When the patient is alone for an extended period of time (between the aide's departure and the daughter's arrival home from work), and she cannot transfer/walk unassisted, she most likely has episodes of incontinence. The patient is unable to provide adequate and safe self-care. This can lead to patient discomfort, and possible attempt to get off the bed (which would likely lead to a fall). Remaining in wet soiled diapers increases risk of incontinence associated skin damage (e.g., fungal infection, dermatitis). It also increases risk of pressure ulcers. The need to use the toilet, and episodes of incontinence occur at various unplanned times throughout the day; and so, the patient needs a caregiver throughout the day for all toileting related tasks, including incontinence care. 

MLTC (Managed Long-Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. These care needs must be considered in the determination of the patient's personal care service hours. 

Considering the family is requesting CDPAS 70 hours per week, it is reasonable to conclude that there are no informal caregivers who can provide this many hours of care on a regular basis throughout the week. The patient needs frequent care during the day and evening, and at least a few times during the night for toileting/incontinence care, and repositioning. Assistance from informal caregivers is voluntary, as per NYS (New York state) regulations for personal care services. When informal caregivers cannot consistently provide assistance with daily activities when needed, then personal care services (in this case CDPAS) are medically necessary to provide assistance with IADLs and ADLs when needed throughout the day and night. 

Home Care/Personal Care HHC (Home Health Care) - Level 2 Personal Care Services, per 15 minutes, 70 hours per week are medically necessary. 70 hours per week applies to CDPAS (which are currently in place) or it can apply to standard personal care aide services if the family wants to change to standard PCA (Personal Care Assistance) services. 

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 services (CDPAS) for 70 hours per week is overturned. Medical Necessity is substantiated.