Diagnosis: Coronary heart disease, diabetes mellitus, heart failure.

Treatment consumer directed personal assistance program (CDPAP) of 9 hours per day, 7 days per week for a total of 63 hours per week.

The insurer denied coverage for consumer directed personal assistance program (CDPAP) of 9 hours per day, 7 days per week for a total of 63 hours per week.

The denial is overturned.

The patient has a history of coronary heart disease, diabetes mellitus, heart failure, cerebral atherosclerosis, vascular dementia, hemiplegia following a cerebral infarct, chronic kidney disease (Stage 4), hyperlipidemia, atrial fibrillation and benign prostatic hyperplasia. Per the New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, his wife and consumer directed personal assistance program aide were present. The patient lives with his spouse in a two-bedroom apartment on the first floor of a building with elevator access. He was in SAR [subacute rehabilitation] for a few days. The patient was hospitalized for a urinary tract infection. Later, he fell on his knees while walking on the street. Emergency medical services came and took him to the hospital. No injuries were reported. The patient is currently receiving physical therapy twice a week. He was hospitalized due to generalized weakness

He is totally dependent for meal preparation, ordinary housework, managing finances and shopping. The patient needs maximum assistance with managing medications, phone use, managing stairs, transportation, bathing, personal hygiene, dressing his upper and lower body, locomotion, toilet transfer and toilet use. He is noted to walk ad lib [as needed]. The patient's bladder continence is controlled with a cystotomy to drain his urine. He is frequently bowel incontinent and uses under pads and pull-ups. He needs extensive assistance with bed mobility and eating. The patient uses an assistive device for locomotion.

An increase to consumer directed personal assistance program (CDPAP) from 6 hours per day to 9 hours per day, 7 days per week for a total of 63 hours per week is being requested. The patient has been evaluated twice and was assessed at needing 60 and 56 hours/week. He needs a high degree of hands-on assistance, and his wife and doctor's note he is weaker. The patient's request for 63 hours/week is in keeping with that assessed for in the Tasking tools.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Consumer Directed Personal Assistance Program (CDPAP) of 9 hours per day, 7 days per week for a total of 63 hours per week is overturned. Medical necessity is substantiated.