Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular dementia and Cardiovascular disease. 

Treatment: Consumer Directed Personal Assistance Services (CDPAS) for a total of 12 hour per day, 7 days a week for a total of 84 hours per week.

The insurer denied coverage for CDPAS for a total of 12 hour per day, 7 days a week for a total of 84 hours per week.

The denial is overturned. 

This is a male patient who has an extensive medical history associated with functional impairment. He needs varying levels of assistance with all daily activities. He lives at home with his daughter and son-in-law; his daughter provides care as a Consumer Directed Personal Assistance Services (CDPAS) aide and informal caregiver. The patient is approved for CDPAS 49 hours per week. The daughter requested an increase of services to 12 hours per day, 84 hours per week.

Uniform Assessment System (UAS) documentation was provided for review. The functional status of the patient indicated he was totally dependent for most instrumental activities of daily living (IADLs), except phone use, stairs (extensive assistance) and transportation (maximal assistance). For activities of daily living (ADLs), the patient needed extensive assistance for bathing, lower body dressing, walking, toileting; limited assistance for personal hygiene, upper body dressing; supervision for eating, bed mobility. There was a decline in function since the previous UAS for walking and toilet use from limited assistance to extensive assistance. The patient has a diagnosis of vascular dementia. Based on the most recent UAS, it appears the patient is cognitively impaired to the extent that it affects some aspects of his daily function. Cardiovascular disease appears to have the most substantial impact on the patient's daily life. He has an extensive cardiac history including severe coronary artery disease status post Coronary Artery Bypass Grafting (CABG) and stents; history of heart block with pacemaker, systolic heart failure, and peripheral artery disease.    

Considering the patient's medical history and functional status, it is medically necessary for him to have a caregiver present throughout the day to assist with all daily activities, including scheduled activities and unscheduled. In their final denial letter, the insurer indicated that with CDPAS, the hours are flexible and can be used throughout the day. However, for activities that are occur at various, unscheduled times of the day, a caregiver needs to be available throughout the day to assist the patient when needed. By splitting 7 hours into 3 or 4 hour shifts morning and evening, then the patient does not have assistance for ADLs during the other hours of the day. Tasking tools cannot accurately quantitate total time for aide services or identify specific times of the day for aide services when ADL assistance is needed at various unscheduled times throughout the day. The patient lives with his daughter, but it should not be assumed or expected that all care needed beyond 7 hours per day must be provided as informal care.  As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary. The daughter reported that her day as CDPAS aide starts at 5:30 in the morning. The daughter needs to be available to help her father during all daytime hours until evening when he goes to bed. Without continuity of care throughout the day, the patient is at risk for adverse health and safety events (for example, falls/injury, increased frequency of incontinence, malnutrition, and aspiration). There was no description of nighttime care needs and no request for night hours; and so it appears that the daughter or another family member provides informal support at night if needed.

The health plan did not act reasonably with sound medical judgment.

The carrier's denial of coverage for CDPAS for a total of 12 hour per day, 7 days a week for a total of 84 hours per week is overturned. The medical necessity is substantiated.