Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atherosclerotic heart disease, hypertension, hyperlipidemia, and atrial fibrillation.
Treatment: Level 2 consumer directed personal assistance services (CDPAS) for 80 hours per week.

The insurer denied coverage for level 2 consumer directed personal assistance services (CDPAS) for 80 hours per week.
The denial is overturned.

The patient has multiple medical conditions contributing to functional impairment and requiring assistance with daily activities. As per UAS (Uniform Assessment System), the patient lives alone in a separate apartment in her daughter's house (separate entrances). The patient had been receiving personal care services, provided as Consumer Directed Personal Assistance Services (CDPAS) 80 hours per week. 

The most recent UAS provided for review was done. The functional status report for Instrumental Activity of Daily Living (IADL) indicated patient was totally dependent for meal preparation, housekeeping, shopping; she needed extensive assistance for managing finances and medications, stairs, transportation; limited assistance for phone use. The only change from the previous UAS was for transportation, which was reported as maximal assistance; so, for this IADL, there was some improvement.

For ADLs (Activities of Daily Living), the UAS indicated patient needed maximal assistance for bathing and lower body dressing; extensive assistance for personal hygiene, upper body dressing, toilet transfer, toilet use; limited assistance for walking, locomotion, bed mobility; setup help for eating.

The patient's impaired mobility is a serious risk for adverse consequences. As noted, it likely increases the occurrence of incontinence. When the patient is alone, and she needs something in her home that is out of reach, it is realistic to expect she may try to get up and walk. The UAS nurse reported patient has slow unsteady gait, and she needs caregiver assistance with walking for safety. This is not stand-alone safety supervision. This is ADL assistance that is necessary to complete an activity properly and safely, which is within the scope of care for personal care aides (in this case CDPAS). When an elderly person with functional impairment is alone at home and needs to perform a task, there is no choice but to attempt the activity even if the person does not feel secure performing the task alone. When the person has impaired judgment and decreased safety awareness, the risk for falls/accidents is greater.

The patient's need for assistance with all mobility (transfers and walking) does not support the decision to decrease the amount of assistance she has during the day. 

The patient has several risk factors for falls including lower extremity joint stiffness and decreased ROM (Range of Motion), lower back pain, incontinence, cognitive impairment, fatigue, weakness. When older people fall, there is increased risk of serious injury (e.g., fractures, head trauma) associated with substantial morbidity and increased risk of death. Even a relatively minor injury (e.g., strains, sprains, soft tissue injury) can result in pain and further functional decline. Few, if any, interventions can prevent all falls; but the purpose of fall assessment is to identify risk, and when necessary, develop a plan to decrease the occurrence of falls. When a caregiver is present, the patient has assistance with mobility around her home, including transfers, walking. When the patient is alone, she can only rely on her walker, which does not appear sufficient based on observations from the UAS nurse. Caregiver assistance can provide stability and (when needed) weight-bearing support.  It is reasonable to expect that it is less likely the patient will fall when she has a caregiver present to assist with mobility.
                                                                                    
Based on the patient's medical history and functional status, it is medically necessary for the patient to have assistance with all daily activities. This includes preparation and service/setup for all 3 meals, household related tasks, medications; routine ADLs (including bathing daily; personal hygiene and dressing morning and evening); ADLs that occur at various unscheduled times of the day (e.g., transfers, walking, toileting/incontinence related tasks). 

MLTC (Managed Long-Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all the patient's care needs must be considered in the determination of the patient's personal care service hours. 

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 level 2 consumer directed personal assistance services (CDPAS) for 80 hours per week is overturned. Medical necessity is substantiated.