Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease

Treatment: Consumer Directed Personal Assistance Program (CDPAP) services 76 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance Program services 76 hours per week

The denial is overturned

This patient has advanced dementia (reported as Alzheimer's disease in the UAS (uniform assessment system)) which has resulted in functional decline for daily activities. She lives with her husband. It was noted that due to her husband's health issues, he is unable to assist his wife with daily activities. The patient receives personal care services, provided through Consumer Directed Personal Assistance Program (CDPAP). Two family members were identified as CDPAP aides, providing assistance with ADLs (activities of daily living) and IADLs (instrumental activities of daily living) 56 hours per week, 8 hours per day (noted as 9am (morning) - 5pm (evening). The family also provides some informal help during non-CDPAP hours. As per insurer's final denial letter and encounter notes, the patient's daughter reported the patient needs more help with walking and transfers; and due to progression of Alzheimer's disease, she is more dependent for ADLs. The daughter (as patient designee) requested increase of CDPAP services to 76 hours per week, which was denied. An external appeal was requested. 

The most recent UAS provided was reviewed. The functional status report for IADLs indicates the patient is totally dependent for most IADLs, except transportation (maximal assistance) and stairs (extensive assistance). For ADLs, the patient needs maximal assistance for bathing, upper and lower body dressing, personal hygiene; extensive assistance for toilet use, eating; limited assistance for walking, locomotion, transfer toilet; supervision for bed mobility. 

The MLTC (managed long term care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. These care needs must be considered in the determination of the patient's personal care service hours. Currently the patient has CDPAP services 8 hours per day. This is insufficient, considering she needs help with ADLs that occur throughout the day from morning through at least early evening hours. The appealer requested CDPAP services 76 hours per week. This can provide the patient with assistance from the morning (e.g., 8-9am) through early evening (e.g., 7-8pm). It cannot be assumed that informal caregivers will provide the additional care each day. As per NYS (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 (in this case CDPAP) are indicated to provide assistance with ADLs and IADLs when needed throughout the day. 

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 consumer directed personal assistance program (CDPAP) 76 hours per week is overturned. Medical Necessity is substantiated.