Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease

Treatment consumer directed personal assistance (CDPAS) services of live-in, 7 days per week, consumer direct 1 client

The insurer denied coverage for consumer directed personal assistance (CDPAS) services of live-in, 7 days per week, consumer direct 1 client

The denial is overturned

The patient is an elderly male with a medical history of advanced Parkinson's disease with autonomic dysfunction, postural hypotension, ataxia, dysphagia, dementia, depression and suicidal ideation during a hospitalization. Per letter by physician, the patient recently underwent an endovascular stent graft repair for an enlarging abdominal aortic aneurysm with dissection. The procedure was complicated by stenosis and endoleak which required further intervention. The patient also developed a post-operative urinary tract infection and retention which required an indwelling foley catheter and antibiotics. The catheter was subsequently stopped. The doctor explained that the patient's overall condition has deteriorated since his hospitalization, as he is totally dependent on his consumer directed personal assistance services (CDPAS) aide for care and services. The patient has generalized weakness and deconditioning. This has resulted in difficulty ambulating, caused issues with the patient's blood pressure and has placed him at risk for falls. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and CDPAS aide were present on the call.  The patient resides in a private home with the CDPAS aide, who is a non-relative. 

The patient has limited mobility and difficulty in standing unassisted for periods of time. He needs assistance with all activities of daily living and instrumental activities of daily living. The patient has also experienced a decline in his status due to increased weakness, difficulty walking and poor endurance. He is totally dependent for ordinary housework. The patient needs maximum assistance with meal preparation, managing stairs, shopping, transportation, bathing, dressing his lower body and toilet use. The patient has a foley catheter in place following a recent hospitalization. The patient is also infrequently bowel incontinent. He needs extensive assistance with managing finances, managing medications, phone use, equipment management, personal hygiene, dressing his upper body, walking, toilet transfer, eating, bed mobility and locomotion.  The patient uses an assistive device for locomotion. 

"(a) Definitions and scope of services.

1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The patient has multiple functional impairments from Parkinson's. He is incontinent. The documentation submitted indicates he needs total care 24 hours/day, and is unable to do many tasks on his own, including toileting, changing pullups, transferring, toilet use. Multiple sources note his dependence and his recent deterioration after a long hospitalization. The need for 24-hour care is supported.

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

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance (CDPAS) Services of live-in, 7 days per week, consumer direct 1 client is overturned. Medical Necessity is substantiated.