Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gait instability
Treatment:  Increase in consumer directed personal assistance services from 24 to 40 hours (hrs) per week
The insurer denied increase in consumer directed personal assistance services from 24 to 40 hours (hrs) per week.
The determination is overturned.

This is a female patient with a past medical history of urinary incontinence, dizziness, gait instability, shortness of breath, fatigue, left knee pain, left ankle pain, and low back pain who had been assigned Consumer Directed Personal Assistant Program (CDPAP) services 24 hours/week. The patient had been involved in a motor vehicle accident and was hospitalized and transferred to rehabilitation. The patient was discharged to home. The patient underwent a video assessment. Notes from assessment stated the patient lived alone and had no informal help and was left alone for 8 hours/day.
There was a medical review and practitioners order form completed by medical provider noting patient needed assistance with mobility at maximum assistance. The insurer sent a final adverse determination denial notice stating the patient had requested an increase in CDPAP services stating she needed more help during the day, specifically with doctors' appointments, laundry, home exercise, hygiene, nails, ordinary housework, and therapy. The denial stated the current hours per week were enough to support the patient's current activities of daily living and New York State regulations did not require personal care assistant (PCA) services for safety and supervision alone. The denial also stated the patient could call her care manager regarding setting up grab bars and a shower chair in her home and could discuss the fall prevention program and have a physical therapy assessment to prevent falls. Lastly, the denial stated escort to medical appointments would be approved as needed and this service was additional time from the patient's already approved weekly PCA hours. The patient's primary care physician (or provider) (PCP) appealed the denial decision stating the patient's current home health aide services were not enough for the patient as she was not able to walk and was now wheelchair-bound. The appeal also stated the patient needed help with laundry, cleaning, shopping, and cooking. At issue is the medical necessity of an increase in consumer directed personal assistance services from 24 to 40 hours (hrs) per week.

The services are medically necessary. There is documentation from the patient's medical provider that the patient could no longer walk and was wheelchair-bound, which was a change in status from her previous video assessment. The patient, therefore, requires more assistance hours per week, as she had previously been noted to be independent with walking and locomotion based on telemedicine assessment. The requested increase in CDPAP services is not solely for safety and supervision, but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, CDPAP services 40 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.