Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease (PD).

Treatment the consumer directed personal assistance services (CDPAS) of 10 hours per day, 7 days per week.

The insurer denied coverage for the CDPAS of 10 hours per day, 7 days per week.

The denial is overturned.

This is the case of an adult male patient who has declining functional ability with daily activities associated with several chronic medical conditions. He lives with his wife. He receives personal care services as Consumer Directed Personal Assistance Services (CDPAS), 28 hours per week, 4 hours per day. His wife is identified as the only informal caregiver in the New York State Department of Health's Uniform Assessment System (UAS-NY). In her letter, she indicates that due to her own health issues she is unable to provide the assistance her husband needs. The patient requested increase of CDPAS to 10 hours per day, 70 hours per week, which was denied. An external appeal was requested.

The UAS (Uniform Assessment System) indicates patient is totally dependent or needs maximal assistance for housework, meal preparation, shopping; extensive assistance with medications, stairs, transportation; limited assistance for finances; set up help for phone use. For activities of daily living (ADLs), the patient needs extensive assistance for bathing and lower body dressing, and limited assistance for all other ADLs. 

The patient has Parkinson's disease (PD) which affects motor function causing symptoms such as tremors, bradykinesia, rigidity, abnormal gait, postural instability. Some non-motor effects of PD include sleep disorders, pain, constipation, orthostatic hypotension, dizziness, fatigue, cognitive impairment, mood disorders. There are various medications to manage the motor symptoms of PD. The primary drug is carbidopa-levodopa which is generally necessary for patients with at least moderate severity of symptoms. However, when the effect of each dose of carbidopa-levodopa wears off, the patient can experience significant decline in function ("off" periods) until the next dose takes effect. This can result in unpredictable changes in mobility and ADL function throughout the day.

Urinary incontinence increased. The UAS reported occasional incontinence; and another UAS reported frequent incontinence. There may be various contributing factors. The patient has benign prostatic hyperplasia (BPH) which can cause increased frequency of urination. The wife reported the patient can no longer dress himself, and so changing a pullup unassisted is probably difficult. It would be helpful if a caregiver was available through the day to assist with all toileting-related tasks in order to maintain adequate hygiene, patient comfort, decrease risk of falls/accident during toileting, and decrease risk of skin damage (e.g., dermatitis) due to delay in incontinence care.

Assistance from informal caregivers is voluntary, as per NYS (New York State) regulations for personal care services. The patient has only one informal caregiver, i.e., his wife who is unable to provide the level of care the patient needs throughout the day. Therefore, without an informal caregiver who can provide care during the day when the patient is most active, then personal care services are indicated to provide necessary assistance with ADLs and IADLs. The patient requested personal care services (as CDPAS) 70 hours per week. CDPAS 10 hours per day will provide assistance with all meals, routine ADLs (dressing, bathing, personal hygiene) and unscheduled, recurring ADLs including toileting, incontinence care, transfers, ambulation, including assistance when the patient wants to go outside the home during the day.

CDPAS 7 days per week, 10 hours per day, 70 hours per week is medically necessary. The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient. 

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 10 hours per day, 7 days per week is overturned. Medical necessity is substantiated.