Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.  
 
Treatment: Consumer Directed Personal Care Assistance Services (CDPAS) 40 hours per week.  

The insurer denied Consumer Directed Personal Care Assistance Services (CDPAS) 40 hours per week.  The denial was reversed. 

This is an elderly female with multiple medical conditions and functional impairments.  She needs varying levels of assistance for all instrumental activities of daily living (IADL) and activities of daily living (ADL).  Her functional limitations are a result of physical and cognitive impairments associated with several of her medical problems. She has been diagnosed with: DM, Alzheimer's disease, dementia, lumbar radiculopathy, hypertension, glaucoma, hyperlipidemia, and osteoarthritis. She has difficulty with visual loss, glare sensitivity, urinary incontinence, chronic vertigo, and dry eyes.  Her conditions impair her mobility, balance and vision.  She would benefit from additional hours of assistance (currently 33 hours weekly).  
1) She has an unsteady gait; high risk for falls; lumbar disc disease causing lower extremity symptoms.  She cannot be left alone due to impaired balance and fall risk.  The patient continues to have episodes of dizziness and vertigo.  Physical Therapy (PT) was started for her lower back.  
2) Difficulty was reported with her left eye status post cataract surgery and cannot look at the light.  
3) The patient needs assistance with walking, transfers and other ADLs. 

The nursing comments in the Functional Status section of the UAS stated that the patient has difficulty with transferring and ambulating.  However, immediately after this comment, it is stated that that the patient can ambulate unassisted and without DME in the home.  These statements appear inconsistent.  The patient's medical provider indicated that the patient needs assistance with ambulation due to her medical conditions.  In the UAS ADL assessment, it is documented that the patient needs assistance with walking and locomotion, and she has an unsteady gait.  The patient has multiple risk factors for falls including: arthritis, pain, impaired vision, dizziness, poor balance, unsteady gait, age > 65, incontinence, cognitive impairment, and the use of medications associated with an increased fall risk (antihypertensive drugs, antidepressant).  

It is noted that the daughter provides some assistance with ADLs and IADLs.  However, the full extent of this assistance is not clarified in the available records. In the Social Supports section of the UAS, it is noted that the patient received 9 hours of informal care in the previous 3 days. There are no informal caregivers identified other than the daughter, so it appears that it was the daughter who provided the 9 hours of care.  However, there is no documentation identified describing when the daughter provides care and for which specific activities. 

As per New York State (NYS) regulations for personal care services (in this case CDPAS), care provided by informal caregivers is voluntary.  The daughter is asking for 7 additional CDPAS hours per week.  It is reasonable to conclude that she cannot provide care to her mother during that time. Based on the patient's medical history, symptoms and functional impairments, it is medically necessary for the patient to have assistance with ADLs to ensure safe and timely performance of ADLs.  In the absence of voluntary informal caregivers to provide assistance, it is medically necessary for assistance to be provided by personal care services, in this case, CDPAS. 

The carrier's denial of coverage for the consumer directed personal care assistance services CDPAS 40 hours per week is reversed.  The medical necessity is substantiated.