Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck and back pain with radiculopathy and severely limited range of motion, Diabetes mellitus, Osteoarthritis, Carpal tunnel syndrome

Treatment: Consumer Directed Personal Care Services, 6 hours per day, 7 days per week (total of 42 hours per week)

The insurer denied coverage for Consumer Directed Personal Care Services, 6 hours per day, 7 days per week (total of 42 hours per week).

The denial is overturned. 

This is a female patient who has an extensive medical history associated with functional impairment and needs assistance with daily activities. The patient has been receiving Consumer Directed Personal Assistance Program (CDPAP) services 28 hours per week. A Request was made for an increase of CDPAP services to 42 hours per week which was denied. 

The patient has various medical conditions and symptoms affecting her upper and lower extremities, back and neck, resulting in impaired physical function for daily activities, including the following: neck and back pain with radiculopathy and severely limited range of motion; diabetes mellitus; osteoarthritis; and carpal tunnel syndrome. The Uniform Assessment System (UAS) report describes some other symptoms that most likely contribute to the patient's difficulty with mobility-related activities. The patient has chronic obstructive pulmonary disease (COPD), and has dyspnea with moderate activity. It is also reported in the UAS that the patient has fatigue to the extent that she is unable to finish daily activities. The UAS indicates the patient experiences the combined effects of pain, dyspnea and fatigue on a regular basis. These symptoms increase the burden of performing mobility-related activities, which includes most activities of daily living (ADLs) and instrumental activities of daily living (IADLs); resulting in substantial loss of function and increasing dependence on caregivers for daily activities.

As a result of the patient's medical conditions, symptoms and functional impairment, she needs assistance with mobility related activities, and personal care tasks; including ADLs that occur at various and unscheduled times throughout the day (walking, transfers, toileting/incontinence care). Therefore, it is medically necessary for the patient to have a caregiver available for a more extended period of the day to provide assistance with ADLs. The UAS indicates the patient lives with family; the patient reports she lives alone. In either case, it is apparent from the patient's appeal letter that she does not have assistance throughout the day; and so even if she has some support at times from informal caregivers, it does not appear to be sufficient to help her with unscheduled care needs throughout the day. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. Considering the patient is requesting CDPAP services 6 hours per day, it reasonable to conclude that she does not have informal caregivers who can provide the care she needs for this period of time each day. Without informal caregivers who can provide support with daily activities on a regular basis, then personal care services are indicated to provide assistance with daily activities when needed, including ADLs that occur at various and unscheduled times throughout the day. 

With an increase of CDPAP services to 6 hours per day, it remains unclear how the patient receives assistance with ADLs when the aide is not present. The maximum number of hours that can be approved from this review is limited by the amount of hours requested, i.e. 6 hours per day, 7 days per week, total of 42 hours per week. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for Consumer Directed Personal Care Services, 6 hours per day, 7 days per week (total of 42 hours per week) is substantiated. The insurer's denial is overturned.