Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, Hypertension, Osteoarthritis. 

Treatment: Consumer Directed Personal Assistance Services (CDPAS) 70 hours per week. 

The insurer denied coverage for CDPAS 70 hours per week. 
The denial is overturned. 

This is a female patient with a past medical history of Alzheimer's disease, hypertension, osteoarthritis, transient ischemic attack (TIA), anemia and dyslipidemia. She lives with her son and daughter-in-law. The patient has several medical conditions that have resulted in impaired functional ability for most daily activities. The patient has been receiving personal care services as Consumer Directed Personal Assistance Services (CDPAS) 49 hours per week. An increase in CDPAS to 70 hours per week was requested. 

The most recent Uniform Assessment System (UAS) report was provided for review. The functional status report indicates the patient is totally dependent or needs maximal assistance for most instrumental activities of daily living (IADLs), except managing medications and phone use (extensive assistance). The patient needs extensive (weight-bearing) assistance for bathing, dressing, toilet use; and limited assistance for other activities of daily living (ADLs), except eating (independent, setup help). She has physical limitations that restrict her ability for most ADLs; but her cognitive deficits also affect her ability to safely perform ADLs. Her decision making capacity is minimally impaired. 

Considering the patient's medical history, current active problems and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present to provide ADL and IADLs assistance when needed, including ADLs that occur at unplanned times throughout the day and night, including: toileting, incontinence care, transfers and ambulation. The records provided for review include an activity record that appears to have been completed by the patient's son. Based on these records, it appears the patient needs assistance from family when the aide is not present for ADLs/IADLs during afternoon and evening hours; and all toileting related tasks when needed during night and early morning hours. The family is supportive and has been involved in the patient's care; but it does not appear they can continue to provide assistance on a regular basis. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide the patient with assistance for daily activities when necessary throughout the day and night. 

The maximum amount of hours that can be approved from this review is limited by the amount requested as per the insurer's final adverse determination notice; in this case, CDPAS 70 hours per week. At this time, it is medically necessary and in the patient's best interest to increase CDPAS hours. The additional 3 hours per day will help (10 hours CDPAS per day); but if the family is unable to provide all the additional care needed when the aide is not present it is uncertain whether all the patient's ADL needs will be met. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for the requested increase in CDPAS 70 hours per week is overturned. The medical necessity is substantiated.