Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease, Cervical spinal stenosis, Lumbar radiculopathy with leg weakness.
Treatment: Consumer Directed Personal Assistance Services (CDPAS); 24-hour continuous care, 7 days per week.

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS); 24-hour continuous care, 7 days per week. The denial is overturned. 

This is a female patient with oxygen (O2) dependent chronic obstructive pulmonary disease (COPD), cervical spinal stenosis, lumbar radiculopathy with leg weakness, chronic constipation, abdominal pain, esophageal reflux and nutcracker esophagus. A Uniform Assessment System (UAS) - New York Comprehensive Community Assessment Report was done. The patient was noted to live with her sister and needed more assistance because of pain. Total dependence was noted for ordinary housework; maximal assistance was required for shopping, meal preparation, managing finances, managing medications and managing equipment (oxygen); limited assistance was required for phone use. Maximal assistance was required for bathing, lower body dressing, locomotion, toilet use and toilet transfers. Extensive assistance was required for personal hygiene, upper body dressing and bed mobility. Her primary means of locomotion was a wheelchair/scooter. She had back pain and was currently unable to walk and is wheeled by others. She transfers on and off the commode with two-person assist, is unable to clean herself after going to the bathroom, has frequent urinary incontinence, occasional bowel incontinence, and requires some weight bearing assist to position herself in bed. 

The insurer has denied coverage for Consumer Directed Personal Assistance Services (CDPAS); 24-hour continuous care, 7 days per week. They note that the patient's sister indicates that the patient cannot stand on her own and needs someone to help her change position. They state she does not, however, have continuous hand-on care that is uninterrupted as required by the Managed Long Term Care (MLTC) policies. They state the patient's needs can be met with CDPAS; 56 hours per week.  

The patient's physician notes that the patient's condition has progressed and more services are needed for housekeeping and grooming.  Also, the patient's current aide notes that the patient needs more services. The patient has incontinence and cannot walk. She needs extensive assistance with bed mobility, transfers (commode, wheelchair, and toilet) and toileting. She needs assistance adjusting oxygen. Given the medical conditions and degree of impairment, these services cannot be scheduled on a reliable basis. Her condition has progressed, and her current aide outlines the additional services the patient needs. The additional hours are not just custodial in nature. 

The insurer failed to take into account the information noting the progression of the patient's symptoms and need for assistance. The available information indicates a degree of impairment and need for services that supports 24/7 care.  

Based on the above, the medical necessity for CDPAS; 24-hour continuous care, 7 days per week is substantiated.  The insurer's denial is overturned.