Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's dementia, atrial fibrillation, prior transient ischemic attack
Treatment: Increase Consumer Directed Personal Assistant Services (CDPAS) to 84 Hours/Week
The insurer denied an increase in CDPAS to 84 hours/week.
The denial is upheld.

The patient is an elderly female with Alzheimer's dementia, atrial fibrillation, remote breast cancer status post lumpectomy and radiation, and prior transient ischemic attack who is requesting an increase in consumer directed personal assistant services (CDPAS) to 84 hours/week from 61 hours/week.

Uniform Assessment System (UAS) evaluation completed on recently shows the patient has moderately impaired cognition. She requires maximal assistance with medication management, bathing, hygiene, dressing, walking, toilet transfer, toilet use. She requires extensive assistance with eating. The patient is totally dependent for meal preparation and housework.  

The request was initially denied noting that the current hours are adequate to meet the patient's needs. The denial was appealed. A provider letter notes that the patient has difficulty navigating from room to room and requires assistance with activities of daily living (ADLs). The letter notes that the patient has a tendency to wander and is a fall risk. The provider recommended services for 12 hours/day, seven days/week.    

The plan upheld the denial noting that the request for an increase in services to 84 hours/week was not medically necessary. An appeal letter from the patient's daughter notes that her own health issues make it difficult to help care for her mother and that there is limited family help. Additionally, letters from the patient's neurologist and general physician indicate that the patient has poor balance, experiences sundowning, and that the patient's daughter has found it difficult to help due to her own medical conditions.

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

Consumer directed personal assistance reflects the provision of assistance with personal care services, home health aide services, and skilled nursing tasks by a consumer directed personal assistant under the instruction, supervision and direction of a consumer or the consumer's designated representative. Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. 

This patient has multiple comorbidities including dementia and has requested an increase in CDPAS to 84 hours/week from 61 hours/week. The submitted documentation does not reflect which ADLs cannot be completed with the current 61 hours. The clinical notes submitted in support of the increase state that the patient is at risk for falls and wandering due to her underlying conditions. However, personal care services for companionship or for general supervision for safety is not an indication per New York State guidance. There is no indication that environmental modifications such as locks or cameras, or support items (like incontinence products, bedside commode, grab bars) in the home are unable to keep the patient safe.  Personal care services are not indicated when a patient's needs can be met by equipment or supplies. Additionally, the consumer directed personal assistance program allows for flexibility in allocation of hours such that the patient's representative can split and arrange the existing 61 hours to meet needs throughout the day. Based on the available information, the current 61 hours/week of consumer directed personal assistance are sufficient to adequately meet the patient's needs. Thus, the increase in CDPAS to 84 hours/week is not medically necessary.