Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Depression, Cardiovascular disease, Chronic obstructive pulmonary disease (COPD), Pulmonary hypertension, Chronic pain, Vision loss. 

Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week (split shift); Personal Care Aide (PCA) level 2: 12 hours per day - 7 days(s) per week (split shift) - for a total of 168 hours per week. 

The insurer denied coverage for CDPAP: 12 hours per day - 7 day(s) per week (split shift); PCA level 2: 12 hours per day - 7 days(s) per week (split shift) - for a total of 168 hours per week. 

The denial is overturned. 

This is a female patient who has an extensive medical history and functional impairment. She lives alone and requires assistance with daily activities. She is approved for personal care services as a combination of Consumer Directed Personal Assistance Program (CDPAP) and personal care aide (PCA) services 63 hours per week. The patient's daughter requested CDPAP 12 hours x 7 days (split shift); PCA 12 hours x 7 days (split shift). The most recent Uniform Assessment System (UAS) provided for review was done telephonically. The functional status report indicates the patient is totally dependent or needs maximal assistance for all Instrumental Activities of Daily Living (IADLs). She needs maximal assistance for all Activities of Daily Living (ADLs) except eating (limited assistance). 

It appears the patient has substantial cognitive impairment and behavioral disturbances. For this patient, it is likely that her cognitive impairment is a contributing factor to her dependence on caregivers for IADLs, and possibly some ADLs. The patient's history of dementia and depression has a significant impact on her daily function. The patient's physical function is most likely affected by other medical conditions including: cardiovascular disease, chronic obstructive pulmonary disease (COPD), pulmonary hypertension, chronic pain, and vision loss. Considering the patient's medical history and functional impairment, it is medically necessary for the patient to have a caregiver present to provide assistance for all scheduled activities and ADLs that occur at unscheduled times during the day and night. It is apparent the patient needs assistance with ADLs through the day and night. The patient is awake for extended periods of time at night. Her behavior is unpredictable due to dementia, and so when she needs assistance with ADLs at various times during the night, she needs a caregiver to provide physical support for ADLs. Providing safety precautions during ADL care is part of the scope of practice for personal care services. 

The UAS identified 2 informal caregivers. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at various and unscheduled times through the day and night. As per NYS regulations for 24 hour personal care services, to qualify for a live-in aide, the patient's need for assistance should be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep in an 8 hour sleep period per day. If the patient's ADL needs are too frequent to allow for this amount of sleep for the aide, then continuous services (i.e. split shift) are necessary. The information available for review supports continuous personal care services to provide ADL assistance when needed throughout the day and night. 

The health plan did not act reasonably in the best interest of the patient.

The medical necessity for CDPAP: 12 hours per day - 7 day(s) per week (split shift); PCA level 2: 12 hours per day - 7 days(s) per week (split shift) - for a total of 168 hours per week is substantiated. The insurer's denial is overturned.