Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, and osteoarthritis

Treatment: Consumer directed personal assistance program (CDPAP): 6 hours per day- 7 days per week- for a total of 28 hours per week

The insurer denied coverage for consumer directed personal assistance program (CDPAP): 6 hours per day- 7 days per week- for a total of 28 hours per week

The denial is overturned

This female patient has experienced functional decline associated with several chronic medical conditions. She needs assistance with mobility and performing most daily activities. She lives with her daughter and the daughter's family. The most recent uniform assessment score (UAS) provided was reviewed. Functional status indicates patient is totally dependent for meal preparation, housework, shopping; she needs maximal assistance with medications; extensive assistance managing finances, transportation, stairs; limited assistance with phone use. For activities of daily living (ADL), patient needs extensive assistance for bathing, personal hygiene, dressing upper/lower body, transfer toilet, walking, locomotion; limited assistance for bed mobility, toilet use; setup help for eating. The UAS noted walking, locomotion, transfer toilet needed limited assistance (extensive assistance from previous UAS); indicating decline in patient's mobility. 

The patient lives with her family; her daughter is the CDPAP aide. CDPAP hours are flexible, but it is unrealistic to expect 4 hours to be sufficient for all the patient's care needs throughout the day.  Based on medical history and functional status as noted in the available records, the patient needs substantial assistance for most ADLs and IADLs. Therefore, it is medically necessary, and in the patient's best interest, to have a caregiver present when needed through the day to assist with daily activities. The patient needs assistance for IADLs/ADLs including household tasks; preparation/service of 3 meals per day (except probably 3 meals per week served at social day care); medications; routine morning and evening ADLs (bathing, dressing, personal hygiene); unscheduled, recurring activities, including mobility (transfers, walking), toileting related tasks/incontinence care. Without adequate assistance, the patient is at risk for adverse health and safety events e.g., falls/injury; skin damage due to inadequate toileting/incontinence care.

The UAS indicates patient attends social day care (SDC) 3 days per week, 4 hours per day. CDPAP services are not needed during that time; but the addition of 2 CDPAP hours per day (total of 6 hours per day, 7 days per week) is necessary, even with SDC. The service plan indicates CDPAP hours are currently 4 hours per day in the morning. Additional hours can help with evening ADLs and IADLs (independent activities of daily living), and during the afternoons when the patient does not attend SDC. 

It is within MLTC (managed long-term care) guidelines to provide sufficient CDPAP hours to accommodate the patient's anticipated daily care needs (based on patient's medical history and functional status as reported in the records provided for review). The UAS noted family provides informal help during non-CDPAP hours. Assistance from informal caregivers is voluntary as per NYS (New York state) regulations for personal care services. Considering the patient is requesting (via family representative) CDPAP services 6 hours per day, 7 days per week, it is reasonable to expect that if the patient needs assistance with daily activities beyond 6 hours per day, the family can provide informal help.   
 
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 consumer directed personal assistance program (CDPAP): 6 hours per day- 7 days per week- for a total of 42 hours per week is overturned. Medical Necessity is substantiated.