Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis; Urinary and stool incontinence; Memory impairment.

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

The insurer denied coverage for the CDPAP: 12 hours per day, 7 days per week for a total of 84 hours per week.

The denial is upheld.

This is a female patient with a past medical history of coronary heart disease, heart failure, hypertension, stroke with foot drop, anemia, dyslipidemia, osteoarthritis, urinary and stool incontinence, memory impairment and pre-diabetes. A New York State Department of Health's Uniform Assessment System (UAS-NY) notes that the patient lives in a private home with her daughter and family. The patient's family is very supportive and involved in all aspects of her care. The patient requires assistance with her activities of daily living and instrumental activities of daily living due to her medical problems. The patient also experiences shortness of breath on exertion which is relieved with rest and/or medication.  The patient is totally dependent for meal preparation, ordinary housework, managing finances, and managing medications and shopping.  The patient needs maximum assistance with phone use, transportation, bathing, personal hygiene tasks, dressing her upper body, dressing her lower body, walking, locomotion, toilet transfer and toilet use. The patient is bladder incontinent and occasionally bowel incontinent.  The patient needs extensive assistance with bed mobility and eating. The patient uses a cane along with significant weight bearing support for locomotion indoors. The patient requires significant weight-bearing support from her caregiver for her upper extremities due to pain and joint stiffness.  The patient experiences moderate, intermittent pain which is adequately controlled with her therapeutic regimen.  There were no pressure ulcers, foot problems or skin impairments noted. An increase to Consumer Directed Personal Assistance Program (CDPAP) of 12 hours per day, 7 days per week for a total of 84 hours per week is being requested.

As per the New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016:
(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.

Based on the review of the medical record and literature, additional Consumer Directed Personal Assistance Program (CDPAP) requested is not considered medically necessary for this patient. As per this patient's physician visit and assessments submitted for this review, there are no new needs or any changes in this patient's function that required additional CDPAP hours. The insurer used the information available for assessing the patient's needs, and the available information does not support additional CDPAP hours for this patient. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the requested CDPAP: 12 hours per day, 7 days per week for a total of 84 hours per week is not substantiated.  The insurer's denial should be upheld.