Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, concussion, obesity, and osteoarthritis
Treatment: Consumer directed personal care assistance services (CDPAS), 49 hours per week
The insurer denied coverage for consumer directed personal care assistance services (CDPAS), 49 hours per week
The denial is overturned

This female has experienced decline in function for daily activities associated with chronic medical conditions and effects of head injury (due to fall). The patient lives alone. The Uniform Assessment System (UAS) report indicates patient has no informal helpers. She relies on personal care services [provided as Consumer Directed Personal Assistance Services - (CDPAS)] for assistance with most activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient has been receiving CDPAS 39 hours per week. She requested increase of CDPAS to 49 hours per week, which was denied. An external appeal was requested.

Back and knee pain can also limit ability with other ADLs such as lower body bathing and dressing (noted in UAS as needing extensive assistance). Wrist pain can affect ADLs requiring upper extremity function including upper body bathing and dressing, personal hygiene, toilet use. Depending on severity of wrist pain, this can also affect mobility. The patient relies on use of a cane or walker for stability during transfers and walking, especially when she is alone. Wrist pain can affect proper use of these devices if pain interferes with proper hand grip; and can limit weight-bearing on cane or walker during transfers and ambulation.

The UAS indicates patient needs extensive assistance with personal hygiene, lower body dressing, and limited assistance with upper body dressing. These ADLs occur in the morning and evening. The patient also needs set up help for meals. UAS reported patient can re-heat simple meals; but if she is having increased severity of pain and/or vertigo, then going to the kitchen and performing even simple tasks (e.g., re-heating or transfer of food from refrigerator) may be too difficult and unsafe (she needs to keep at least one hand on the cane/walker or countertop for stability). If an aide is present later in the day, the aide can serve and set up dinner when the patient has more difficulty with mobility at dinner time. One possible use of additional CDPAS hours is to have a second shift early evening so the aide can help with dinner and evening ADLs, including assistance with toileting/incontinence care closer to bedtime. 

The 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 occur at unscheduled, recurring times of the day. The patient lives alone and no informal helpers are identified in the UAS. As per New York State  (NYS) regulations for personal care services, assistance from informal caregivers is voluntary. Considering the request for increase of CDPAS is for 49 hours per week, it is reasonable to conclude that there are no informal caregivers who can 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. CDPAS 49 hours per week will provide useful additional hours for ADL care. 

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 consumer directed personal care assistance services (CDPAS), 49 hours per week is overturned. Medical Necessity is substantiated.