Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder
Treatment: Home Health Care
The insurer denied: CDPAS 
The denial is: Upheld in whole

The patient is a female with past medical history of hypothyroidism, anxiety, narcolepsy with cataplexy, idiopathic hypersomnia, migraines, syncope, sleep apnea (with noncompliance with continuous positive airway pressure [CPAP] therapy), urinary incontinence and conversion disorder.
The patient had Uniform Assessment System (UAS) NY Comprehensive Community Assessment Report tool performed noting the patient needed total assistance with transportation. For the task of shopping maximum assistance was assessed, as necessary. The patient was assessed at extensive assistance for tasks of meal preparation and ordinary housework while limited assistance for tasks of stairs, dressing of lower extremity. Supervision was noted for tasks of managing finances, managing medications and toilet use while patient was felt to be independent with tasks of phone use, personal hygiene, dressing upper extremity, walking, locomotion, transfer toilet, bed mobility and eating. Task tool appropriated 15 hours of personal care aide services (performed through Consumer Directed Personal Assistance Services [CDPAS] program by the patient's sister) although officially assigned 21 hours per week.
The patient then had another assessment performed on in the fall of last year indicating that she was total assistance for transportation otherwise independent for all other tasks. The assessment tool noted that the patient had episodes where all of a sudden, she could not walk, could not feel her legs, and became very fatigued. This is when she needed extra help. According to this assessment tool, the patient had been told by the medical providers that her condition was "in her head". The patient noted that suddenly she would have changes without warning where she could barely feel her legs from the thighs down. It was recommended that the patient go to counseling which she did but there was no change in her condition. The patient has a significant other who works nights, she lives with her 23-year-old child who works part-time and her 13-year-old child who attends school. Following this assessment the patient was assigned no hours of personal care assistance stating that she was independent with tasks. It noted she had improvement in function, change in social situation and there was a mistake on previous approvals. The patient had previously been assessed at 15 hours per week but was erroneously given 21 hours. There were shared activities of housekeeping, shopping, and meal preparation which should not have been allotted PCA time. The patient CDPAS was however reduced to 5 hours per week of PCA services as noted in the final adverse to termination letter. The patient appealed this adverse determination.

The health plan's determination of medical necessity is upheld, in whole.

No, CDPAS is not medically necessary for this patient.
The patient carries the diagnosis of idiopathic hypersomnia, narcolepsy with cataplexy and conversion disorder. The patient was erroneously assigned 21 hours of PCA services per week but had qualified for 15 hours per week on her assessment. The patient lives with her significant other and tasks of meal preparation, shopping and housekeeping are shared activities and therefore not eligible for PCA services. The patient has unpredictable episodes of difficulty with ambulation, chronic fatigue and does not require PCA services on a routine/regular basis. The patient estimates that she has about 3 episodes per month of extreme fatigue and limited use of her lower extremities while her significant other estimated it to be about 7 times per month. There is no documentation from medical provider regarding the medical necessity of PCA services at the patient's baseline functioning or during the episodes of fatigue and inability to feel her legs.