Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: increase in Consumer Directed Personal Assistance Services (CDPAS) from 55 hours to 72 hours per week. 
The insurer denied increase in Consumer Directed Personal Assistance Services (CDPAS) from 55 hours to 72 hours per week. 
The determination is overturned. 

This is a female patient with a history of dementia, diabetes mellitus, headaches, hypertension, hyperlipidemia, polyarthritis, weakness, unsteadiness on feet, anxiety, insomnia, and bladder and bowel incontinence. She lives in a private home with her son and daughter-in-law. The patient was previously approved for 55 hours per week of Consumer Directed Personal Assistance Services (CDPAS). The patient and her care team requested 72 hours per week of CDPAS. 
An in-person Uniform Assessment System (UAS) was completed. A tasking tool was used to determine that she requires 49.42 hours of aide service per week. Another video UAS was completed. The patient was assessed at total dependence for tasks of meal preparation, ordinary housework, managing finances, and shopping; maximal assistance for tasks of managing medications, phone use, stairs, transportation, and bathing; extensive assistance for tasks of personal hygiene, dressing upper body, dressing lower body, walking, locomotion, transfer toilet, toilet use, and eating; and limited assistance for the task of bed mobility. A tasking tool was used to determine that she requires 55.42 hours of aide service per week. 
Her PCP (primary care provider) states that she has severe pain in lower back, both legs, both knees, both ankles, both shoulders as well as generalized weakness and fatigue and that her conditions re progressively getting worse. He states that she is unable to perform most of her daily activities and requires additional home health hours in order to help her with daily activities. At issue is the medical necessity of increase in Consumer Directed Personal Assistance Services (CDPAS) from 55 hours to 72 hours per week. 

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, an increase in Consumer Directed Personal Assistance Services (CDPAS) from 55 hours to 72 hours per week is medically necessary.
There is documentation in the more recent UAS of the patient requiring at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan did not document a plan to meet these unscheduled and unpredictable care needs. The insurer should not have utilized a tasking tool to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. There is documentation from the patient's PCP of the medical necessity of increased aide services. The patient lives with her son and daughter-in-law and therefore has informal support. However, per New York Codes, Rules, and Regulations (NYCRR) 505.14, the plan cannot assume that the informal support person can provide all needed care outside of the approved personal assistance hours as informal supports must be voluntary. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with activities of daily living (ADLs).