Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paraplegia

Treatment: consumer directed personal assistance (CDPA) basic service, 24 hours per day continuous care for a total of 168 hours per week

The insurer denied coverage for consumer directed personal assistance (CDPA) basic service, 24 hours per day continuous care for a total of 168 hours per week

The denial is upheld.

This is an older patient with a history of corticobasal degeneration, secondary parkinsonism, aphasia, paraplegia, and wheelchair dependence. Per the Uniform Assessment for New York (UAS-NY), the patient lives with a daughter in a private home. The family provides some support, and the patient is now total assistance for all self-care and needs extensive care. The family is requesting consumer directed personal assistance (CDPA) basic service, 24 hours per day continuous care for a total of 168 hours per week.

The patient does need assistance with activities of daily living (ADLs) and transfers. The patient lives with a family member who can provide care but requires additional assistance, particularly with transfers. The plan's partially approved hours for the live-in CDPA are appropriate, as this would allow additional help when two-person care is needed. Additionally, hospice may be able to provide additional care outside the CDPA hours. Therefore, 24-hours a day continuous care is not medically necessary.

"In the course of their day-to-day activities, paid caregivers went beyond assisting with activities of daily living by attending to patients' acute medical problems, assisting them with management of their chronic diseases, promoting their general health, and fostering mental health. Paid caregivers, patients, and proxies saw these health-related tasks as core features of the services they provided or received. Moreover, these findings suggest directions in which the paid caregiver workforce may be further developed to achieve better patient outcomes, allow more patients to remain in the community for longer periods of time, and realize greater value for Medicaid dollars spent on long-term care.

"We found that half of the health-related tasks performed by paid caregivers were not included in the basic training for Medicaid-funded paid caregivers in New York. It appears that rather than limiting their tasks to those proscribed by their formal training, paid caregivers individualized and expand their roles to performing health-related tasks they and their clients perceived as appropriate and necessary based on personal and professional attitudes and experience. These findings have implications for standardization of quality and regulatory oversight of this large and growing segment of the health care workforce." (Reckrey et al., 2019).

The medical policy appears to have approved daily live-in personal care aide/assistant hours. The number of hours approved, should allow for adequate care and address the patient's mobility and activities of daily living (ADL) needs.

The requested CDPA, 24-hours per day continuous care for a total of 168 hours per week, is not considered medically necessary for this patient.

Based on the above, the insurer's denial is upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for consumer directed personal assistance (CDPA) basic service, 24 hours per day continuous care for a total of 168 hours per week is not substantiated.