Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's Disease. 

Treatment: Consumer Directed Personal Assistance Services (CDPAS) of 24 hours per day, 7 days per week (live-in).

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) of 24 hours per day, 7 days per week (live-in).

The denial is upheld. 

This is a male patient with a past medical history of Parkinson's Disease (PD), type 2 diabetes mellitus, congestive heart failure (CHF), obstructive sleep apnea (OSA), anemia, osteoarthritis (OA), osteoporosis, hypertension (HTN), hyperlipidemia (HLD), peripheral vascular disease (PVD), myelodysplastic syndrome, gout, spinal stenosis lumbar and emphysema.  The Uniform Assessment System (UAS) - New York notes that the patient lives alone on the first floor of a private home. 

The patient reported that his vision and hearing have declined due to aging.  The patient is also experiencing increased forgetfulness with occasional short term memory loss.  It was documented that the patient's cognition and physical condition are deteriorating due to his disease progression process.  The patient also is experiencing intermittent and chronic pain in his shoulder, lower back, knees and legs due to OA. The patient's pain is controlled with rest and medication.  The patient is totally dependent for meal preparation, ordinary housework and shopping.  The patient needs maximum assistance with managing his medications, transportation, bathing, dressing his lower body, toilet transfer and toilet use.  The patient receives help from the Consumer Directed Personal Assistance Services (CDPAS) personal assistant with administering his insulin injections and taking oral medications due to his cognition and visual impairment.  The patient needs extensive assistance with managing finances, using the phone, personal hygiene tasks, dressing his upper body, walking, locomotion and eating.  The patient uses an assistive device for locomotion indoors.  However, the patient has foot problems which limit his walking ability.  The patient needs limited assistance with bed mobility.  The patient's durable medical equipment at home includes a walker, shower chair, commode, respiratory machine and pull ups.  The patient is occasionally bladder incontinent and infrequently bowel incontinent.  It was noted that the patient has an open wound on his right ankle area, and wound care is being provided by the personal assistant and his son daily as prescribed by a wound care specialist.  The patient currently receives CDPAS of 35 hours per week.  An increase in CDPAS to 24 hours per day, 7 days per week (live-in) is being requested.

As per documentation submitted for this review, the patient has been approved for 42 hours/week and the request is for 168.  The physician letter supports 84 hours/week, not 168.  The assessments done a year apart do not show a degree of deterioration that would support 168 hours/week. The patient's skilled needs are addressed. The patient has no specific night-time needs that are not being addressed with this approved number of hours of services.  The plan has adequately supported the basis for its decision. 

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

The carrier's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 24 hours per day, 7 days per week (live-in) should be upheld.  The medical necessity is not substantiated.