Diagnosis: Fractured Facial Bones, Clavicle and Left Ilium

Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP)

The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP). The denial was reversed.

This is an elderly female patient with a history of coronary heart disease, hypertension, hyperlipidemia, stroke, transient ischemic attack, end stage renal disease, renal dialysis, A-V fistula on hemodialysis, renal osteodystrophy, depression, anxiety, age related cognitive decline, dysphagia, osteoarthritis, falling, gastroesophageal reflux disease and urinary incontinence. She is status post fall where she sustained fracture of her facial bones, left clavicle, and right ilium. Post hospitalization she was transferred to a rehab facility. It was reported that she is wheelchair bound; she cannot walk or take care of herself. It was reported that the patient currently had 30 hours per week of CDPAP but was requesting an increase to 70 hours per week due to the multiple chronic medical conditions and substantial functional impairments she suffers from.

The need for additional CDPAP hours is not for safety supervision alone. Based on the patient's functional deficits and level of assistance needed for all ADLs, it is medically necessary for the patient to have a caregiver present throughout the day and night for all routine scheduled activities; and for those that occur at various and unpredictable times, including toileting, incontinence care, repositioning in bed (due to discomfort/pain, and for pressure relief).

The patient lives with several family members. In the UAS only one informal helper was identified. The circumstances of the other family members and their daily schedules are not known. The family is requesting CDPAP 10 hours per day x 7 days per week. However, the family is still providing assistance and supervision during the other hours of the day/night. Considering the request is for an increase of 4 hours per day x 5 days, plus 10 hours per day for the other 2 days of the week, it is reasonable to conclude that there are no informal caregivers who can consistently provide care for those periods of time. Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services (in this case CDPAP). The family wants to keep the patient safe, and provide necessary care but are unable to do so for these additional hours each day. When informal caregivers are not able to provide necessary care for daily activities, then it is medically necessary for care to be provided by personal care services, in this case CDPAP.

The carrier's denial of coverage for an increase in Consumer Directed Personal Assistance Program (CDPAP) services at 10 hours per day, 7 days a week, for a total of 70 hours per week is reversed. The medical necessity is substantiated.