Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Heart Disease, Heart Attack
Treatment: Consumer Directed Personal Care Assistance services, a total of 91 hours per week

The insurer denied coverage for Consumer Directed Personal Care Assistance services, a total of 91 hours per week.  The denial is modified.

The patient is a patient with a history of diabetes, hypertension, hyperlipidemia, heart disease, heart attack and glaucoma. The patient is status post triple bypass heart surgery. The patient lives with their wife in an apartment, and the patient's son lives near their home. The patient's wife provides informal care, and their son provides formal and informal care assisting with meal prep, laundry, financial management, medication management, and shopping. The patient needs help with bed mobility, toileting, walking, meal prep, housework, and shopping. The patient needs help with bathing, personal hygiene, extensive assistance with dressing upper and lower body, locomotion presentation, and stairs up and down. The patient is continent of bowel and bladder. The patient has a visiting nurse 2 times a week for 30 to 60 minutes for wound care, physical therapy twice a week, and occupational therapy twice a week. Based on assessment tool the total task hours equal to 13.63 per week. 

Based on participant's assessments, medical provider's letter of medical necessity and family and representative letters of support, the participant's level of functioning, debilitation and functional deficits, the patient will require additional hours of Consumer Directed Personal Assistance Services to support and provide their required personal care needs. 

Consumer Directed Personal Assistance Services (CDPAS), a total of 91 hours per week, is not medically necessary for this patient; however, 26 hours per week 7-day plan is not sufficient to support this participant's assisted care needs and maintain safety in the home and community.   

Per the NYS Department of Health Office of Health Insurance Programs, the scope of the CDPAS benefit includes continuous personal care services, which means the provision of uninterrupted care, by more than one person, for more than 16 hours per day for a patient who, because of the patient's medical condition and disabilities, requires total assistance with toileting, walking, transferring or feeding at times that cannot be predicted. The approved 26 hours per week / 7-day plan of CDPAS is not sufficient to meet the patient's assisted care needs and maintain safety within home and the community; therefore, the denial of coverage for Consumer Directed Personal Care Assistance services, a total of 91 hours per week is not medically necessary; however, it is partially overturned for 35 hours per week of Consumer Directed Personal Care Assistance Services is medically necessary. 

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Care Assistance services, a total of 91 hours per week services is not substantiated. However, 35 hours per week of Consumer Directed Personal Care Assistance Services is medically necessary.