Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease, benign prostatic hypertrophy (BPH), osteoarthritis (OA), and hypertension
Treatment: CDPAP (Consumer Directed Personal Assistance Program) - 16 hours per day- 7 days per week- a total of 112 hours per week

The insurer denied coverage for CDPAP- 16 hours per day- 7 days per week- a total of 112 hours per week.
The denial is overturned.

This patient has significant functional impairment and needs assistance with all daily activities. The patient had been living with his wife, but she has not been residing at home lately. She was hospitalized and it appears she was transferred to a rehab facility, but it is not clear when she is returning home. The patient has two daughters involved in his care. One daughter who resides overseas came to NY (New York) to help care for her father (and initially also her mother); and it appears she has been staying in his home, but she plans to return to her home abroad (to her husband and child). Another daughter lives close to the patient (not with him) and helps a few days per week. Another relative is also involved in the patient's care. The patient has been receiving personal care services as Consumer Directed Personal Assistance Program (CDPAP) services, 8 hours per day, 7 days per week, 56 hours per week. The Clinical Review Checklist identifies the daughter who lives locally and another relative as the CDPAP aides. It was also noted the patient and his wife were part of a mutual case when she was home. It is not known how many total hours were provided when both were receiving services. The daughter who lives overseas reported patient's care needs have increased and he needs 24-hour care. She requested increase of CDPAP services to 112 hours per week, 16 hours per day, 7 days per week, which was denied. An external appeal was requested. 

Regarding the patient's toileting care, the daughter reports patient has urine and bowel incontinence. It is unclear whether he still knows when he needs to use the toilet. The daughter's comments suggest he is mostly incontinent. The UAS (Uniform Assessment System) indicates the patient needs maximal assistance for toilet transfer and toilet use, and what appears to be total dependence for incontinence care.  With the description of the patient's need for maximal assistance with toileting, and frequent incontinence (including his behavior of removing/refusing diapers), it is apparent the patient needs a caregiver available 24 hours per day. The insurer's final denial letter stated the patient's care needs can be met safely with CDPAP 8 hours per day. This conclusion is inconsistent with a patient who needs such high level of care for all toileting related tasks. The patient's dependence on caregivers for toileting and incontinence care requires 24-hour care. If there is insufficient assistance for incontinence and toileting (which occurs at various unplanned times of the day and night), the patient is at high risk for incontinence associated skin damage (e.g., dermatitis, fungal infection), increased risk for pressure ulcers, and high risk for falls if he tries to get out of bed unassisted. It was noted the patient does not want a bedside commode, as his bed is close to the bathroom. Even with a bedside commode, the same care would be needed to transfer the patient from bed to commode, cleaning, clothing adjustment, and incontinence care. 

As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. As described in the UAS, the patient is unable to provide adequate self-care for any ADLs (Activities of Daily Living). It is medically necessary for the patient to have caregiver services available to accommodate the patient's recurring and unscheduled ADL care needs when they occur during the day and night. The patient's care needs can be met through a combination of CDPAP services and informal care.

Consumer Directed Personal Assistance Program services, 16 hours per day, 7 days per week, total of 112 hours per week are medically necessary. 

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 Consumer Directed Personal Assistance Program (CDPAP)- 16 hours per day- 7 days per week- a total of 112 hours per week is overturned. Medical necessity is substantiated.