Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, dizziness/vertigo, osteoarthritis, low back pain, gait abnormality,
 
Treatment: Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day, Level 6 CDPAS

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day, Level 6 CDPAS. The denial is reversed. 

This patient is a female with diagnoses: diabetes mellitus type 2 with diabetic nephropathy, hypertension, hyperlipidemia, congestive heart failure (CHF), degenerative joint disease (DJD), gastroesophageal reflux disease (GERD), dizziness/vertigo, and neuropathy. The patient lives at home with daughter. The patient has multiple medical conditions that have substantial impact on her daily function. Most IADLs and ADLs need high level of assistance from extensive to maximal to total dependence (except bed mobility: limited assistance).  The UAS indicates the patient can walk a few feet, but the physician records report that patient is wheelchair bound. The patient has been receiving consumer directed personal assistance services (CDPAS) 12 hours per day, 7 days per week. She switched to a new health plan. The new plan reduced CDPAS to 10 hours per day, 7 days per week.

Elderly people with multiple health problems often experience significant functional decline as a result of various symptoms and changes in physical and mental capabilities. The patient has several chronic conditions that can cause substantial limitations to performing daily activities. It is apparent that the patient has substantial functional impairments for all daily activities. Several ADLs and IADLs can be scheduled within a limited timeframe each day. However, some ADLs cannot be scheduled, as they can occur at any time, i.e. transfers, walking, toileting/incontinence care. 

The late-2019 UAS specifically noted that since the last assessment, the patient's ADL status declined and self-sufficiency deteriorated. This does not appear to support the decision to decrease CDPAS hours. It is understood that assessment tools are needed to determine allocation of services. However, looking at numbers/scores does not necessarily reflect the actual needs of the patient. Considering the patient's medical history of chronic progressive diseases; information from physicians; and review of the UAS reports, there does not appear to be indication of clinical improvement that would support less hours of caregiver assistance each day.

If the patient had a caregiver who could provide the necessary care for additional hours each day, then decrease in CDPAS hours could be considered. Assistance from informal caregivers is voluntary, as per NYSD regulations for personal care services. The only informal caregiver identified is the daughter who lives with the patient. Information from the previous insurer's records indicated that the daughter is disabled and has limited ability to help her mother, but is willing to assist after CDPAS hours. The extent of the daughter's disability and the hours the daughter is home each day is not known from this review; but is it reasonable to conclude that if she was able to provide additional care to her mother, she would not have requested continuation of CDPAS 12 hours per day. 

Based on the above, the medical necessity for Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day, Level 6 CDPAS is substantiated.  The insurer's denial is reversed.