Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cancer, anemia, heart disease, hypertension, hyperlipidemia, atrial fibrillation, and osteoarthritis.
Treatment:  Consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week.

The insurer denied coverage for consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week.  The denial is modified.

The patient has functional impairment associated with various medical conditions and needs assistance with all Activities of Daily Living (ADLs) and Instrumental activities of daily living (IADLs). The patient lives alone since the death of spouse. The patient has been receiving personal care services through Consumer Directed Personal Assistance Program (CDPAP) 42 hours per week.

The most recent Uniform Assessment (UAS) was reviewed. The functional status report for IADLs indicated the patient was totally dependent for ordinary housework, managing finances; required maximal assistance for meal preparation, managing medications, stairs, shopping, transportation; extensive assistance for phone use. For ADLs, the patient needed maximal assistance for bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use, bed mobility; extensive assistance for personal hygiene, dressing upper body; setup help for eating. 

Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. All the patient's care needs during the day and night must be considered in the determination of personal care service hours. 

It is medically necessary for the patient to have help with all scheduled and unscheduled/recurring ADLs and IADLs morning through evening. The patient needs some help with ADLs at night (such as toileting/incontinence care, bed mobility/repositioning). Additional service hours are not for stand-alone safety supervision. The patient needs frequent and substantial assistance for safe and proper completion of all ADLs; preparation/service of all meals; assistance with medication. This can help prevent adverse medical events, ensure adequate food and fluid intake, and help with pain relief.

The records indicate the daughters have been providing care as CDPAP aides and as informal helpers. The daughter/designee can provide some informal help at night. The patient's daughter is no longer able to meet the patient's care needs during daytime/evening hours. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. When informal caregivers are unable to provide necessary care, personal care services are indicated to provide assistance with ADLs and IADLs when needed, day and night. Considering the frequent and high level of assistance the patient needs for ADLs/IADLs during day and evening hours, CDPAP 6 hours per day (current services) is not sufficient. CDPAP hours are flexible, and can be used when needed, day, evening and night; but should be commensurate to the frequency and level of care the patient requires. 

Recommendation is given to approve Consumer Directed Personal Assistance Program services 12 hours per day, 7 days per week: 84 hours per week.

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 consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week is partially substantiated. The recommendation is given to approve Consumer Directed Personal Assistance Program services 12 hours per day, 7 days per week: 84 hours per week.