Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/ Circulatory Problems.
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Live-in per diem - 24 hours per day - 7 days per week.

The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Live-in per diem - 24 hours per day - 7 days per week.  The health plan's determination is overturned in part. 

The patient is a female with a past medical history significant for dementia, hypertension, coronary artery disease, congestive heart failure, osteoporosis, degenerative joint disease, lumbar muscle spasms, urinary incontinence and physical decline secondary to contracting Covid (Coronavirus disease) 19.

The patient was approved for consumer directed services for a total of 6 hours per day, 7 days per week for a total of 42 hours per week. The request is for is for the medical necessity of consumer directed personal assistance program per live in per diem, 24 hours per day 7 days a week.

Services were denied by the health plan based upon lack of medical necessity.

No, the requested service of live-in per diem 24 hours a day 7 days a week was not medically necessary for this patient. However, the patient requires additional assistance subsequent to the illness, along with the progression of her underlying medical problems. However, 24-hour services are not medically necessary. An increase in services to 12 hours per day  7 days a week is medically necessary.

The personal statement was noted from the patient's designee. The physician statement noted that the patient's physical status has declined and recommended 7 days a week  12 hours a day of home care services.

Her plan had approved 6 hours per day, 7 days a week for a total of 42 hours a week, stating that the patient does not meet criteria for 24 hours a day services. Patient requires limited assistance for dressing upper and lower body, personal hygiene, walking, locomotion toilet transfer. Patient required extensive assistance for toilet use and medication management. Patient required maximal assistance for bathing. Patient is totally dependent for meal preparation and housework. Patient was able to walk with light touch with assistance of a walker.

Uniform Assessment System (UAS) State of New York was reviewed.

The patient is an elderly female with multiple medical problems with ongoing dementia, progressive physical and mental decline subsequent to Covid 19 infection. She had an evaluation by the nursing staff, which was noted. Her physician provided a statement,  which notes that the patient did have physical decline over the last few months. It is reasonable to increase the patient's services, due to the physical decline since the previous nursing/UAS evaluation. The provided services 42 hours a week may not be enough to take care of her needs, a newer assessment is not available for review subsequent to the patient's physical mental decline.

Services for preventing falls and observation are typically included in the provided services allowed for under the evaluation. Specifically, the aid must be performing a service such as in activities of daily living (ADL) or Instrumental activities of daily living (IADL) to be a covered service. Aide services for watching the patient in the middle of the night without actually performing a medically necessary ADL would be considered observation and typically not a service provided under the terms of the plan. The documentation provided did not note specific needs for 24 hour a day  7 days a week services. Physician documentation also did not support this increase.