Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Intracranial abscess, metastatic breast cancer, dysphagia, obsessive-compulsive disorder (OCD), and epilepsy.
Treatment:  Consumer Directed Personal Assistance Services, 1 Client Live-in 7 Days/Week.

The insurer denied Consumer Directed Personal Assistance Services, 1 Client Live-in 7 Days/Week.  
The denial is upheld.

This patient is an adult female with medical conditions that include an intracranial abscess, metastatic breast cancer, dysphagia, obsessive-compulsive disorder (OCD), and epilepsy. Denial of consumer direct, live-in, seven days per week, is being appealed. The health plan approved Consumer Directed Personal Assistance Services (CDPAS) of 40 hours per week.

Uniform Assessment System (UAS) evaluation completed 6 months ago shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and managing finances and medications; extensive assistance with transportation; supervision with bathing, personal hygiene, and eating; and independent with dressing, walking, locomotion, toileting, and bed mobility. She is continent. Compared to Uniform Assessment System evaluation completed last year; there has been no significant decline. An appeal statement from New York State notes the patient is currently living in rehabilitation. She is often confused. She does not sleep through the night and has a history of wandering. She requires assistance with activities of daily living (ADLs). She lives alone and requires 24-hour care. A letter from the patient's daughter notes the patient needs 24-hour care, due to her confusion and getting up in the middle of the night.

The proposed treatment is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living, including toileting, walking, transfers, turning/positioning, or feeding. This patient has multiple chronic conditions and recent admission for intracranial abscess. The denial of CDPAS, live-in, seven days per week is being appealed. The health plan approved: Consumer Directed Personal Assistance Services (CDPAS) of 40 hours per week. 

Uniform Assessment System (UAS) evaluation completed 6 months ago shows the patient is independent with dressing, walking, locomotion, toileting, and bed mobility. She requires supervision with bathing, personal hygiene, and eating. She requires assistance with meal preparation, housework, managing finances and medications, and transportation. Appeal statement notes the patient needs 24-hour care due to her confusion and wandering during the night. The information provided shows no support tasks being performed that require 24-hour care. Consumer Directed Personal Assistance Services is not indicated for management of chronic companionship or supervision. The increase in Consumer Directed Personal Assistance Services to live-in, seven days per week, is not medically necessary. The approved Consumer Directed Personal Assistance Services 40 hours per week is appropriate to meet this patient's needs for assistance with activities of daily living.