Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Home Care/Personal Care Consumer Directed Personal Assistance Services (CDPAS) increase to 84 hours per week

The insurer denied coverage for Home Care/Personal Care Consumer Directed Personal Assistance Services (CDPAS) increase to 84 hours per week

The denial is overturned

This case involves an elderly patient who lives with family and has their son and friend as their paid caregivers. The patient was noted to have a diagnosis of dementia without behavioral disturbance, insomnia, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, unspecified, other polyosteoarthritis, other osteoporosis without current pathological fracture, overactive bladder, unspecified abnormalities of gait and mobility, unspecified urinary incontinence, dizziness and giddiness, syncope and collapse, presence of right artificial hip joint, mixed incontinence, essential (primary) hypertension, fecal urgency, vitamin D deficiency, weakness, other fatigue, age-related physical disability, unspecified dementia without behavioral disturbance, and irritant contact dermatitis. Current medications include Toviaz, vitamin C, Namenda, amlodipine, carvedilol, vitamin D3, and Breo Ellipta. 

According to the Tasking Tool, 35.42 hours of formal support is needed weekly to meet the patient's needs: 8.75 hours of assistance with meal preparation, 5.83 hours of assistance with toileting, and 3 hours of assistance with laundry is needed weekly. 

According to the Uniform Assessment System (UAS-NY), the patient has moderately impaired cognition, procedural and short-term memory problems, is alert and oriented x 1 to person, rarely talks, has periods of confusion and forgetfulness due to severe dementia and is unable to describe an emergency plan or dial 911 if needed. The patient has adequate hearing and vision, is alone for less than 1 hour per day, ambulates with a slow and unsteady gait, uses a wheelchair, has a walker but requires weightbearing assistance for very short distances, and mainly stays in bed. The patient is frequently incontinent of bowel and bladder. It was noted that the patient has modified independence with nutritional intake and requires supervision when eating. No hospitalizations or falls were noted in the past 90 days. 

According to the latest Tasking Tool, 45.33 hours of formal support is needed weekly to meet the patient's needs: 7 hours of assistance with meal preparation, 3 hours of assistance with ordinary housework, 2 hours of assistance with shopping, 3.5 hours of assistance with bathing, 5.25 hours of assistance with toileting, 5.25 hours of assistance with eating, and 3 hours of assistance with laundry is needed weekly. 

The health care plan did not act reasonably and with sound medical and in the best interest of the patient. 

Consumer Directed Personal Assistance Services increased to 84 hours per week is considered medically necessary for this patient, as the patient has demonstrated a decline in health, is unable to contact emergency services, requires weightbearing assistance, is dependent for most activities of daily living, has an unsteady gait and has a history of severe dementia. The request for an increased number of Consumer Directed Personal Assistance Services hours is medically appropriate to allow for improved safety and prevent caregiver fatigue. As such, the denial of Consumer Directed Personal Assistance Services increased to 84 hours per week is overturned.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Assistance Services increase to 84 hours per week is substantiated.