Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Palsy

Treatment: Increased Consumer Directed Personal Care Assistance services, 10 hours per day, 7 days per week (Monday through Sunday), total of 70 hours per week.

The insurer denied coverage for Increased Consumer Directed Personal Care Assistance services, 10 hours per day, 7 days per week (Monday through Sunday), total of 70 hours per week.

The denial is modified.

This is a patient with chronic medical problems including Cerebral Palsy, spastic diplegia, cervical and lumbar radiculopathy and chronic pain in ankles and feet.  The patient lives with his parents.  The patient has had no visits to the emergency department or hospitalizations in the last 90 days.  The patient has fallen once outside when they were unassisted. The patient has no visual impairment and is continent of bladder and bowel function.

The New York State (NYS) Comprehensive Assessment form was thoroughly reviewed and referenced. The patient's cognitive function is described as modified independent with no significant memory loss. The patient needs extensive assistance for weight bearing and manages only with a wheelchair and motorized scooter. The patient needs extensive assistance for upper and lower body dressing, bathing, full weight bearing, toileting and toilet transfers. The patient also needs maximal assistance for shopping, meal preparation and housework. The patient has an emergency plan for assistance and is independent for phone use. The patient's physician confirms the patient's described functions in activities of daily living (ADL) and instrumental activities of daily living (IADL) listed above. The hours approved assist the patient with the tasks listed. 

Personal Assistance Services (PAS) hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance. 
 
Based on the enclosed documents reviewed, the patient's health and safety cannot be appropriately provided and maintained with 42 hours of PAS hours/week. 
 
The carrier's denial of increased hours per week of PAS services is not medically appropriate.  The patient can be safely managed with 8 hours per day, 7 days per week, for a total of 56 hours weekly of PAS services, an increase from the 42 hours currently approved by the carrier. 
The carrier's decision to deny an increase in PAS services should be modified to allow for 8 hours per day, 7 days per week, for a total of 56 hours per week. These hours can be used flexibly to best meet the patient's needs, including their need for toileting, toilet transfer, dressing, bathing and limited weight bearing.
 
Based on the above, the insurer's denial must be modified. 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 an increased Consumer Directed Personal Care Assistance service, 10 hours per day, 7 days per week (Monday through Sunday), total of 70 hours per week is not substantiated. However, PAS services should be modified to allow for 8 hours per day, 7 days per week, for a total of 56 hours per week.