Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease, asthma, congestive heart failure, anxiety, depression, atherosclerotic heart disease

Treatment consumer directed personal assistance services (CDPAS) of 24 hour continuous care, 7 days per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) of 24 hour continuous care, 7 days per week

The denial is overturned.

The patient has a past medical history of chronic obstructive pulmonary disease, asthma, congestive heart failure, anxiety, depression, atherosclerotic heart disease, myocardial infarction, pleural effusion, coronary angioplasty, supra-valvular aortic stenosis, prosthetic heart valve, hypertension, osteoarthritis, hypokalemia, insomnia, iron deficiency, constipation, muscle weakness, abnormality of gait and mobility, non-rheumatic mitral valve disorder and bladder and bowel incontinence. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, her daughter and her son were present on the call. The patient lives alone in a one bedroom apartment on the first floor. English is not her language.  Family members and a private hire are with the patient when the personal care aide is not present, but the patient is left alone for approximately 30 minutes at a time. The patient speaks to her family members on the phone on a daily basis. The patient had one fall last month but no injuries. The patient's daughter reported that the patient is frail. She takes Ambien 5 milligrams for her diagnosis of insomnia, but she gets up during the night if she has a coughing episode or needs to use the bathroom. 

Needs are: 

-Total dependence for meal preparation, ordinary housework and managing stairs;
-Maximal assistance for managing finances, managing medications, phone use, shopping, transportation, equipment management, bathing, dressing her upper and lower body, walking, bed mobility, locomotion (uses AD [assistive device]), toilet transfer and toilet use;
-Extensive Assistance for personal hygiene;
-Limited assistance for eating;
-Cognition: 	There is mild impairment. 
-Continence: 	There is frequent urinary and occasional bowel incontinence. She uses pull-ups.

The patient uses a walker and has contact guarding with ambulation. An increase to Consumer Directed Personal Assistance Services (CDPAS) of 24 hour continuous care, 7 days per week is being requested. There are no scheduled informal caregivers. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:

"(a) Definitions and scope of services.
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

This is a patient with advanced age and multiple co-morbidities who needs assistance with all functions. She can briefly ambulate with contact assistance but needs maximal assistance with transfers and toileting. Use of the extremities is impaired as demonstrated by need for maximal assistance with dressing and extensive assistance with personal hygiene. As a result, she cannot manage her toileting needs, and she has unscheduled needs due to incontinence.  In order to not be stuck with soiled pull-ups for potentially many hours, 24-hour care is supported. The provision of diapers and durable medical equipment (DME) such as alternate pressure beds is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers changing diapers regularly and positioning are also necessary. 

There are no scheduled informal caregivers. The health care plan did not act reasonably with sound medical judgment.

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 24 hour continuous care, 7 days per week is reversed. Medical Necessity is substantiated.