Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness. 
Treatment: Consumer directed personal assistance Services (CDPAS) of 56 hours per week, Consumer Direct, 1 client. 

The insurer denied coverage for consumer directed personal assistance Services (CDPAS) of 56 hours per week, Consumer Direct, 1 client. 

The denial is overturned. 

This patient has several medical conditions contributing to functional impairment which has limited her ability to perform daily activities. She receives assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through personal care services, provided as Consumer Directed Personal Assistance Services (CDPAS) 49 hours per week. She lives with her son.  The uniform assessment score (UAS) indicates the son provides care, but it is not clear whether he is CDPAS aide, or provides informal help after CDPAS hours, or both. The patient requested increase of CDPAS to 56 hours per week which was denied. 

The patient has increased frequency of dizziness most likely contributes to patient's need for assistance with mobility. Some common causes of dizziness in older people include vestibular dysfunction, orthostatic hypotension, side effects of drugs. The patient reported going to the emergency department for dizziness and was discharged the next day; no details are available. The Medical Request for Home Care included diagnoses dizziness and vertigo (uses meclizine prn "when required"). 

The patient needs limited assistance with toilet transfer and toilet use. Limited assistance does not require weight-bearing assistance, but for a person with impaired balance and gait instability, it can be the difference between safe performance of tasks and the occurrence of falls/accidents. The patient needs assistance with toilet use; this may be due to shoulder pain causing difficulty with cleaning, and back pain causing difficulty bending for clothing adjustment. She now needs assistance with toilet transfer (she needed only supervision at the time of the uniform assessment system. This is likely due to pain and stiffness of knees and lower back which affects the ability for all transfers. With joint pain and dizziness, the patient is at risk for falls in the bathroom, which is associated with higher risk of injury. 

The UAS does not report the occurrence of falls in the previous 90 days. The comments in the external appeal application indicate the patient had falls going up and down stairs due to knee and leg pain. 

The level of care the patient needs as reported in the UAS is greater for several ADLs compared to other UAS, including those that occur at unscheduled, recurring times of the day. CDPAS is provided to meet the level of care needed; the same as for standard PCA services. Tasking tools are useful, but do not always provide an accurate allocation of time needed for assistance with ADLs/IADLs for all people. This patient's care needs extend through the entire day, and so it is medically necessary to provide assistance for routine activities (IADLs, routine ADLs), and for mobility and toileting which occurs at unscheduled, recurring times of the day. CDPAS 56 hours per week, if equally divided, is 8 hours per day. It is not clear whether this covers all care needed from morning until patient goes to bed at night. CDPAS hours are flexible, and so 8 hours per day may be scheduled in a way for this to work. The patient lives with her son. He may be available for all other assistance needed beyond 8 hours of CDPAS per day. No other informal caregivers are identified. As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. Considering the request for increase of CDPAS is for 56 hours per week, it is reasonable to conclude that informal caregivers are unable to provide care for that amount of time each week. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services (in this case CDPAS) are indicated to provide assistance with ADLs and IADLs when needed throughout the day. 

The health plan did not act reasonably in the best interest of the patient. 

Based on the above, the medical necessity for the requested Consumer Directed Personal Assistance (CDPAS) of 56 hours per week, Consumer Direct, 1 client is substantiated. The insurer's denial is overturned.