Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, Chronic pain syndrome, Altered mental status

Treatment: 168 hours per week, Consumer Direct, 1 Client services

The insurer denied coverage for 168 hours per week, Consumer Direct, 1 Client services.

The denial is overturned.

This is a female patient with multiple medical conditions and substantial functional impairment who lives alone in her own home. She is legally blind and has a history of atrial fibrillation, hypertension, hyperlipidemia, chronic kidney disease stage 3, chronic pain syndrome, osteoporosis, altered mental status, and bilateral hip fractures (status post pinning). Following two hip fractures in the past, the patient was in a nursing home for rehabilitation for several months before returning home.

Over the past few months, the patient has been receiving consumer directed personal assistance services (CDPAS). The patient was initially approved for 32 hours per week. The family requested an increase of services to 168 hours per week, which was denied; but services were increased to 42 hours per week. On appeal, a request for 168 hours per week was denied; but services were increased to 56 hours per week. The patient advocate reported that the family is paying privately for aide services for the other 16 hours of the day. The patient's son requested an external appeal for CDPAS 168 hours per week.

The most recent Uniform Assessment System (UAS) was provided for review. Assessment of the patient's functional status indicated that the patient needed extensive or maximal assistance, or total dependence for all instrumental activities of daily living (IADLs). The patient needed extensive or maximal assistance for most activities of daily living (ADLs), except for personal hygiene and bed mobility (i.e., needed limited assistance) and eating (i.e., needed independent setup help). The UAS indicates that the patient has short term memory impairment. The patient's decision-making capacity for daily tasks was noted as minimally impaired; the patient was not self-directing except in daily routine; and in certain situations, her decisions were described as poor or unsafe.

Based on the review of the patient's medical conditions and functional impairment, it is medically necessary for the patient to have caregiver assistance for all daily activities, including ADLs that occur at unscheduled times throughout the day and night, i.e. transfers, toileting/incontinence care, transport by wheelchair to bathroom, or transfer to a bedside commode; and scheduled repositioning throughout the day/night in chair or bed for pressure relief. The UAS identified 2 informal helpers who do not live with the patient and provide limited assistance. The patient's family is privately hiring aides for the hours the CDPAS aide is not with the patient. Assistance from informal caregivers is voluntary as per the NYS regulations for personal care services (in this case CDPAS). When informal caregivers are unable to provide care for the patient needs, then personal care services are indicated to provide necessary assistance with all daily activities as needed throughout the day and night. Based on the description from an aide who reported this patient's day and nighttime ADL needs, it does not appear that there is a consistent, predictable 5 hour period of time each day when an aide can have 5 uninterrupted hours of sleep as required by the NYS regulations for live-in aide services. Therefore, continuous services, i.e. CDPAS 168 hours per week, split shift, are considered medically necessary for this patient.

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

Based on the above, the medical necessity for 168 hours per week, Consumer Direct, 1 Client services is substantiated. The insurer's denial should be overturned.