Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, type 2 diabetes, osteoarthritis, hypertension, and malignant neoplasm of the kidney

Treatment: Increase in CDPAP (Consumer Directed Personal Assistance Program) services Personal Assistance Program 15 hours per day- 7 days a week for a total of 105 hours per week

The insurer denied coverage for increase in CDPAP services 15 hours per day- 7 days a week for a total of 105 hours per week

The denial is overturned

This female patient has severe functional impairment associated with chronic medical conditions and exacerbated by acute medical events which occurred in the past few months. The patient is dependent on caregivers for all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She receives personal care services, provided as Consumer Directed Personal Assistance Program (CDPAP), 84 hours per week, 12 hours per day, 7 days per week. The patient lives with her daughter, who also provides informal help during non-CDPAP hours. Following recent hospitalizations and admission to skilled nursing facility (SNF) for rehabilitation, the patient (via designee) requested increase of CDPAP services to 105 hours per week, 15 hours per day, 7 days per week, which was denied.

The patient has Alzheimer's disease which is probably a substantial cause of her functional impairment. Based on the UAS (with history from daughter), it appears the patient has advanced dementia. As per UAS, the patient's decision-making ability for daily activities is severely impaired. Due to patient's lack of response to questions during assessment, memory could not be assessed; but at the time of the UAS, the patient had short term and procedural memory loss. Her verbal communication skills are limited to concrete requests. She has episodes of disorganized speech. The nurse reported patient said things that were not relevant to the situation. 

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple medical conditions. Other factors include social and economic circumstances (e.g., caregiver support). 

As per New York State regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed throughout the day. With CDPAP services, there may be an indistinct line between formal and informal care. If the patient's CDPAP hours are not increased, the daughter will need to continue to provide care as an informal caregiver (if she is able to continue to provide this level of care). However, CDPAP services should be commensurate to the level and frequency of care needed; the same as for standard personal care assistance (PCA) services.  CDPAP services, 15 hours per day, 7 days per week, total of 105 hours per week are medically necessary. 105 hours per week can be used for CDPAP services, or standard PCA services or combination of both.

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 an increase in Consumer Directed Personal Assistance Program (CDPAP) services 15 hours per day- 7 days a week for a total of 105 hours per week is overturned. Medical Necessity is substantiated.