Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease and a closed fracture of multiple ribs of the left side with routine healing. 
Treatment: Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week.

The insurer denied coverage for Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week.  
The denial is overturned. 

This is a female patient with a past medical history of Alzheimer's disease, hyperlipidemia, chronic obstructive pulmonary disease, urinary incontinence, esophageal reflux disease, obesity, iron deficiency anemia, anxiety, diabetes mellitus, hypoxia, a closed fracture of multiple ribs of the left side with routine healing, nausea, interstitial lung disease, Rheumatoid factor positive, polycythemia and pain. She has significant functional impairment associated with various medical conditions. The patient lives with her daughter and grandchildren. She receives consumer directed personal assistance program services (CDPAP) services. The patient was approved for CDPAP 20 hours per week (4 hours per day, 5 days per week). The patient's daughter requested CDPAP 56 hours per week (8 hours per day, 7 days per week) which was denied, but the insurer increased CDPAP services to 5.5 hours per day, 7 days per week; total 38.5 hours per week. The patient's daughter requested an external appeal as designee for the patient.

Uniform Assessment System (UAS) documentation was provided for review. The functional status report indicates the patient is totally dependent or needs maximal assistance for most instrumental activities of daily living (IADLs); except phone use, stairs, transportation (limited assistance). For activities of daily living (ADLs), the patient needs extensive assistance for bathing, lower body dressing, toilet use. For all other ADLs, the patient needs limited assistance; except bed mobility (supervision). 

Considering the patient's medical history, and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present to provide assistance with ADLs and IADLs when needed, including ADLs that occur at unplanned times throughout the day and night, including: toileting, incontinence care, transfers and ambulation. Caregiver assistance is needed to help prevent adverse health and safety events.

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services (in this case CDPAP) are indicated to provide the patient with assistance for daily activities when necessary throughout the day and night. If the patient's care needs become more frequent and/or the family's ability to provide informal care decreases, re-assessment will be needed to determine if CDPAP 8 hours per day can adequately meet the patient's personal care needs.

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 the requested Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week is overturned. Medical necessity is substantiated.