Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 12 hours per day, 84 hours per week.
The insurer denied the Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 12 hours per day, 84 hours per week.
The health plan's determination is upheld.

The patient is a female with a past medical history significant for Alzheimer's disease, insomnia, bilateral hearing loss, back pain, osteoarthritis, scoliosis, hypertension and chronic kidney disease.

Services were denied by her insurance stating the following: your activities of daily living during a calendar day, such as grooming, dressing, bathing, walking, locomotion, transferring, toileting, meal preparation and feeding are sufficiently infrequent and can be safely and adequately met through a combination of CDPAS for 7 days a week, for 5 hours per day for total of 35 hours week combined with the planned coordination of care and appropriate medical professionals and specialized equipment as necessary. Clinical documentation includes the patient's Uniform Assessment System (UAS) for the state of New York, physician letters and appeal letters. Personal care hours were determined by a tasking tool. The tasking tool notes that 3.6 hours a day are sufficient to meet your needs. Seven days a week of CDPAS(Consumer Directed Personal Assistance Services) services for 5 hours per day of total 35 hour week were approved.
Per a letter from an advocacy group, the patient has a psychiatric condition and they state that the member becomes anxious and confused when the health aide leaves. They note that hearing loss affects the patient's ability to understand conversations and she is not fully aware of her surroundings. She needs cueing and prompting from the aid and relatives along with constant reminders to complete activities of daily living (ADL's). The patient is not requesting additional hours for safety monitoring and supervision but rather because she needs additional hours of assistance with ADL's such as meal preparation, managing medications, housework and bed mobility. The advocacy group states that the plan had an inaccurate assessment.
The UAS from the state of New York was reviewed and this assessment was completed with the patient's daughter-in-law and notes that the patient lives alone but the family stays with her. As per the daughter-in-law, her son assists the patient with her medications and the patient wants to administer the nighttime medications. An evaluation noted that the patient often understands conversation with minimal difficulty hearing. The patient needs limited assistance with most of her ADL's. The patient is totally dependent in most instrumental activities of daily living (IADL's). 
An audiology evaluation noted patient does have a significant hearing deficit. Her physician requested that the patient have additional services. The progress notes state that her mental capacity and Alzheimer's disease is stable.
The patient did have a functional decline which would be expected based upon her age and underlying medical conditions. However, based upon the patient's assessment, her functional abilities do not require additional services beyond 5 hours a day which were noted in assessment. In the appeal it states that the patient is requiring additional services for meal preparation, housework and bed mobility. The patient has adequate bed mobility, transfers and locomotion as noted in UAS. There were no medically significant changes documented. As far as additional services for meal preparation and housework, I think that would not have substantially changed between the last 2 assessments. The patient had total dependence for meal preparation and housework based upon her UAS evaluation. It also is noted, according to the daughter-in-law, that patient has some family services to help at night with nighttime medications.