Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, cardiovascular disease, cerebrovascular disease, and osteoarthritis.

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day, 5 days per week; 8 hours per day, 5 days per week; and Consumer Directed Personal Assistance Program (CDPAP) Services for 12 hours per day, 2 days per week; 8 hours per day, 2 days per week; for a total of 140 hours per week.

The insurer denied coverage for PCA Level 2: 12 hours per day, 5 days per week; 8 hours per day, 5 days per week; and CDPAP Services for 12 hours per day, 2 days per week; 8 hours per day, 2 days per week; for a total of 140 hours per week.

The denial is overturned. 

This is a female patient who has substantial functional impairment associated with various medical conditions. The patient lives with her daughter. She receives personal care services 84 hours per week, 12 hours per day, as a combination of Personal Care Aide (PCA) services 5 days per week and Consumer Directed Personal Assistance Program (CDPAP) 2 days per week. The family requested increase of services to include an additional 8 hours of PCA services 5 days per week and additional 8 hours of CDPAP services 2 days per week (total of 20 hours per day, 7 days per week; total 140 hours per week). 

Uniform Assessment System (UAS) documentation was provided for review. The functional status report indicates the patient is totally dependent or needs maximal assistance for all Instrumental Activities of Daily Living (IADLs). The patient needs maximal assistance for most Activities of Daily Living (ADLs), except bathing: total dependence; eating: extensive assistance. Medical conditions contributing to the patient's functional decline include: dementia, cardiovascular disease, cerebrovascular disease, and osteoarthritis. Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have a caregiver present through the day and night to provide assistance with all routine daily activities, and with ADLs that occur at multiple and unplanned times throughout the day and night. 

Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. Considering the family is requesting 8 additional PCA hours 5 days per week it is reasonable to conclude that informal caregivers are unable to provide 8 hours of care after the 12 hour PCA shift ends 5 days per week. It is also necessary to increase hours the other 2 days of the week, which is requested as CDPAP services. It is not clear whether the daughter is able to serve as CDPAP aide for 20 hours per day, or if another caregiver will provide additional assistance as a second CDPAP aide. There are 4 hours each day not specifically covered in the request for increased services. CDPAP hours can be flexible and adjusted to best manage the patient's care needs. The family may be able to manage the patient's evening and nighttime care 2 days per week with flexible use of the additional 8 CDPAP hours. For the 5 days of PCA services per week, the daughter, or possibly another informal caregiver, may be able to provide assistance when needed during the 4 hours of the day when the PCA is not present.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.
                                                                                 
The insurer's denial of coverage for PCA Level 2: 12 hours per day, 5 days per week; 8 hours per day, 5 days per week; and CDPAP Services for 12 hours per day, 2 days per week; 8 hours per day, 2 days per week; for a total of 140 hours per week is overturned. Medical necessity is substantiated.