Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, diabetes, stroke, hyperlipidemia, peripheral arterial disease, vertigo, hypertension, and wandering
Treatment: Home care/ personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week
The insurer denied coverage for Home care/ personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week
The denial is overturned.

This elderly patient has extensive medical history associated with physical and cognitive impairment and needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives at home with her husband. She receives personal care services (PCS). At the time of the most recent Uniform Assessment System (UAS) report, she was receiving PCS as Consumer Directed Personal Assistance Services (CDPAS) 35 hours per week. The patient (via designee) requested increase of PCS to 84 hours per week, which was denied; but PCS was increased to 42 hours per week. An external appeal was requested.

The most recent UAS was reviewed. The functional status report for IADLs indicates patient was totally dependent for meal preparation, ordinary housework, managing finances and medications, shopping; she needed maximal assistance for phone use; extensive assistance for stairs, transportation. For ADLs, the patient needed extensive assistance with bathing, personal hygiene, dressing upper/lower body, transfer toilet, toilet use; limited assistance with walking, locomotion; supervision for bed mobility, eating. 

Due to physical and cognitive impairment, it does not appear the patient can safely and effectively manage toileting related tasks unassisted. Without adequate help, adverse health and safety events can occur including falls walking to the bathroom; falls in the bathroom; inadequate cleaning/hygiene which increases risk of incontinence associated skin damage. 

The patient needs assistance for stability, and when needed, weight-bearing support with transfers and walking. 

The UAS indicates the patient lives with her husband, but it does not appear he assists with the patient's care (due to his own health). The UAS reports other family members serve as CDPAS aides and informal helpers. UAS section A includes a comment stating that one daughter "stays over but doesn't live there" which appears to indicate a daughter stays with the patient at night, and possibly another family member comes during the day. 

As per New York State regulations for PCS, assistance from informal caregivers is voluntary. CDPAS hours should be commensurate to the level and frequency of care needed, the same as for standard personal care aide services. It should not be assumed that either CDPAS aides or other informal helpers will provide all other care the patient needs beyond the approved PCS/CDPAS hours.

A comment in the Fair Hearing request form states that the aide is exhausted. It is not known how the family wants to utilize the additional hours (continue as CDPAS; or use standard personal care aide services; or combination of both). The 84 hours per week can be used for CDPAS services, or standard personal care aide services, or combination of both.

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

The insurer's denial of coverage for the home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week is overturned. Medical necessity is substantiated.