Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, polyneuropathy, cognitive decline (age related), dyslipidemia, glaucoma, and diabetes
Treatment: Increase in Consumer Directed Personal Assistant Services (CDPAS) level II to 84 hours/week
The insurer denied the increase in CDPAS level II to 84 hours/week.
The denial is upheld.

The patient is an advanced age elderly female with multiple medical comorbidities including osteoarthritis, polyneuropathy, cognitive decline (age related), dyslipidemia, glaucoma, and diabetes who was initially receiving 21 hours/week of Consumer Directed Personal Aide Services (CDPAS). The request was for an increase in CDPAS level II to 84 hours/week.

A physician note indicates that the patient has severely limited hearing and vision and limited mobility, requiring 24/7 care. Uniform Assessment System (UAS) evaluation completed this year reflects that the patient requires extensive assistance with bathing, dressing the lower body and walking. The assessment showed that she needs limited assistance with personal hygiene, dressing the upper body, toilet transfer and toilet use. A tasking tool notes an estimated 31.1 hours/week of activities requiring assistance.

The request for increase in hours was partially denied by the plan, with a decision noted to approve 35 hours/week CDPAS level II. 

The patient's son initiated a verbal request for an appeal. In a later decision, the plan upheld the decision to deny the increase to 84 hours/week and maintain 35 hours/week CDPAS. In their denial, the plan argues that safety and supervision would be the main reasons for an increase in hours, which is not allowed by New York State Regulations. The plan felt that the approved hours were sufficient to meet the patient's needs.

The increase in CDPAS level II to 84 hours/week is not medically necessary.

Personal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. The request is for an increase in home/personal care to 84 hours/week from 21 hours/week. While the accompanying physician letter notes that the patient needs more assistance due to vision and hearing issues as well as limited mobility, the submitted documentation does not reflect which activities of daily living (ADLs) cannot be completed with the 35 hours/week that were approved by the plan. Moreover, the time-based tool completed recently reflects that allocated time for each of the patient's ADLs amounts to 31.1 hours/week, which is less than the 35 hours that were approved. Additionally, the patient is noted to be part of the consumer directed personal assistance program, which allows for flexibility in allocation of hours such that the patient's representative can split and arrange the existing 35 hours to meet needs throughout the day. Additional hours beyond those approved would be for supervision and safety concerns. However, CDPAS cannot be approved for the purpose of supervision, per New York State Guidelines. Based on the available information, the 35 hours/week of PCS are sufficient to adequately meet the patient's needs. Thus, the increase in CDPAS level II to 84 hours/week is not medically necessary.