Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, angina, peripheral vascular disease, insulin dependent diabetes, diabetic neuropathy, diastolic heart failure, and renal insufficiency.
Treatment: Consumer Directed Personal Aide Services (CDPAS) for 49 hours per week.

The insurer denied coverage for CDPAS for 49 hours per week.
The denial is overturned.

This male has extensive medical history associated with functional impairment and needs assistance and/or supervision for most daily activities. The insurer's final denial letter indicates patient lives with his sister. The Uniform Assessment System (UAS) indicates one informal helper; child or child-in-law who does not live with the patient (the sister is not identified as an informal helper). The patient primarily relies on personal care services, provided as Consumer Directed Personal Assistance Program (CDPAP) services. The patient had been receiving CDPAP services 49 hours per week. The insurer decided to reduce CDPAP to 42 hours per week. The patient requested an appeal to continue CDPAP 49 hours per week, which was denied. The patient requested an external appeal. 

Functional decline in older people is usually the result of cumulative and interactive effects of multiple medical conditions. Other factors include economic and social circumstances, (e.g., caregiver support). The patient's medical history includes several conditions that most likely affect his functional status.

The patient has increased frequency of pain, increased frequency of dizziness, persistent difficulty with sit to stand transfers. The physician's recent letter/office notes provide additional medical history that explains probable cause for the patient's functional impairment and the need for assistance with most daily activities [including heart failure, unstable angina, frequent hypoglycemia, severe leg pain from diabetic peripheral neuropathy (DPN), severe peripheral vascular disease (PVD), back and joint pain]. The patient primarily depends on personal care services (provided as CDPAP) for assistance/supervision with daily activities, including all instrumental activities of daily living (IADLs), routine activities of daily living (ADLs) (bathing, dressing, personal hygiene), and ADLs that occur at various unscheduled times throughout the day (i.e., toileting, transfers, ambulation). The patient has physical impairments that increase his risk for falls and household accidents. He has diabetes with unstable glucose control, which includes episodes of hypoglycemia (he takes insulin); and so, he requires reliable, easy access to meals to decrease risk of hypoglycemia. Assistance with daily activities can help ensure safe, effective completion of ADLs and help relieve some of the stress the patient experiences to complete daily tasks.

With consideration of the issues impacting the patient's health and safety, it is medically necessary, and in the patient's best interest, to have caregiver assistance for a more extended period of the day. The UAS identified one informal helper (child or child-in-law) who does not live with the patient. Considering the patient wants to continue CDPAP services 49 hours per week, it is reasonable to conclude that informal caregivers are not available to provide assistance to replace the CDPAP hours that were eliminated (7 hours per week). 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 necessary assistance for daily activities, including ADLs that occur at unscheduled and recurring times throughout the day.

CDPAP hours are flexible, and so the 49 hours can be allocated to provide assistance during times of the day that can best meet the patient's daily care needs.

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

The insurer's denial of coverage for Consumer Directed Personal Aide Services (CDPAS) for 49 hours per week is overturned. Medical Necessity is substantiated.