Appeal type: Medical necessity
Decision: Overturned

Diagnosis: paroxysmal atrial fibrillation, ejection fraction at 50%, coronary artery disease, chronic obstructive pulmonary disease (COPD), shortness of breath (SOB), and hypertension.

Treatment is Consumer Directed Personal Assistance Services - CDPAS) 28 hours per week.

The insurer denied coverage for Consumer Directed Personal Assistance Services - CDPAS) 28 hours per week.
 
The denial is overturned.

This female patient has functional impairment associated with several medical conditions. She needs assistance with most instrumental activities of daily living (IADLs) and activities of daily living (ADLs). The patient has been receiving personal care services (provided as Consumer Directed Personal Assistance Services - CDPAS) 28 hours per week. She attends social day care (SDC) 4 days per week. The patient requested increase of SDC to 5 days per week, which was denied. An external appeal was requested.

NYS (New York State) Office for the Aging indicates eligibility for social day care is a person who needs assistance of another person in at least one of the following activities of daily living: toileting, mobility, transferring, eating; or who needs supervision due to cognitive and/or psychosocial impairment. The standard for eligibility for social day care based on need for ADL assistance was noted in the insurer's Appeal Decision Notice.

The patient has personal care services at home (CDPAS) 28 hours per week to assist with ADLs and IADLs (it is not known if she has CDPAS 4 hours per day or if hours are allocated differently through the week). The UAS (uniform assessment system) reported the patient needs assistance for toilet transfer and toilet use. In addition, considering the patient's h/o knee pain, fatigue, shortness of breath, low endurance, it is reasonable to consider that help with mobility (transfers and walking) may be needed at times, especially when symptoms are worse. Toileting and mobility occur at unscheduled and recurring times of the day. On the days when the patient does not attend SDC, she has help only from CDPAS. The 4 days per week she attends SDC, she has expanded hours of assistance including CDPAS hours at home plus the hours at SDC. When she is at SDC, she also most likely receives a meal; so, this is one less meal per day that requires preparation (as per UAS, the patient needs extensive assistance at home for meal preparation, and setup help for eating). Attendance at SDC provides additional help for daily activities that occur at unscheduled and/or recurring times of the day, beyond CDPAS hours (e.g., toileting, meals).
 
The most recent UAS provided was reviewed. Therefore, the UAS, the Clinical Appeal Review Summary, and the social worker's letter, plus some clinical information from the cardiologist are the most recent sources of information for this review. The patient meets criteria for SDC services, and she has been attending SDC 4 days per week. She could benefit from additional assistance with ADLs and meals on a 5th day per week, i.e., the same benefits she receives each day during the 4 days she currently attends SDC (in addition to her CDPAS hours at home). The additional socialization and participation in activities of interest can help with management of the patient's anxiety and depression. Considering the patient's ADL care needs and her mental health history, it is medically necessary, and in the patient's best interest for the patient to receive SDC services 5 days per week.

Based on the above, the insurer's denial must be overturned. 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 increase of Social Day Care from 4 to 5 days per week services is substantiated.