Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Consumer Directed Personal Assistance Program (CDPAP) services 12 hours per day, 7 days per week total of 84 hours per week
The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP) services 12 hours per day, 7 days per week total of 84 hours per week 
The denial is overturned

This is an advanced elderly patient who has physical and cognitive impairment and needs substantial assistance with all daily activities. The patient lives alone. She has been receiving assistance for all activities of daily living (ADLs) and instrumental activities of daily living (IADLs) from personal care services provided through the Consumer Directed Personal Assistance Program (CDPAP). The CDPAP aides are family members. The insurer approved CDPAP services 63 hours per week (9 hours per day). The patient's daughter (as patient designee) requested increase of CDPAP services to 84 hours per week, (12 hours per day), which was denied; but CDPAP services were increased to 66.5 hours per week, (9.5 hours per day). 

The most recent Uniform Assessment System (UAS) provided was reviewed. The functional status report indicates the patient is totally dependent for all instrumental activities of daily living (IADLs), except phone use (maximal assistance). For activities of daily living (ADLs), the patient is totally dependent for bathing, dressing lower body, and toilet use; she needs maximal assistance for personal hygiene, dressing upper body, bed mobility; and extensive assistance for eating. It was reported that the patient is bedbound.

The patient is in bed day and night, and she needs maximal assistance with bed mobility; and so, caregivers need to reposition the patient on a regular basis to prevent pressure injury. Guidelines generally include a turning schedule every 2-3 hours (which may vary with circumstances). Incontinence also increases the risk of pressure ulcers. When incontinence care is done, this is an opportunity to reposition the patient. If the patient does not need incontinence care for an extended period of time, then repositioning as a separate task is necessary. 

As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary. With CDPAP services, there may be an indistinct line between formal and informal care. If the patient's CDPAP hours are not increased, the family members who serve as CDPAP aides will need to continue to provide care as informal caregivers. However, CDPAP hours should reflect the frequency, time and level of care needed for all tasks through the day and night. The patient needs assistance with ADLs and IADLs from morning to evening, and she also needs assistance at night (e.g., incontinence care; repositioning; pain medication prn); but the family is not asking for CDPAP 24 hours. The daughter requested CDPAP services 84 hours per week, 12 hours per day (the 12 CDPAP hours can be used throughout the day and night). Currently approved CDPAP services is 9.5 hours per day. The additional 2.5 CDPAP hours per day is fair, reasonable, and medically justified to ensure proper ADL and IADL care through the day, evening and night. The patient needs assistance at various times over 24 hours to help prevent skin damage (due to incontinence, pressure), infection (e.g., UTI), choking/aspiration; help relieve pain; ensure adequate food and fluid intake daily.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for increase in Consumer Directed Personal Assistance Program (CDPAP) services 12 hours per day, 7 days per week, total of 84 hours per week is substantiated.