Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Chronic obstructive pulmonary disease, Heart failure
Treatment: Personal Care Services 12 hours a day, 7 days a week
The insurer denied coverage for Personal Care Services 12 hours a day, 7 days a week.
The denial is overturned. 

This is a female patient who has an extensive medical history associated with substantial functional impairment. The patient lives alone and needs assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient was hospitalized for COVID-19 pneumonia which resulted in significant physical and cognitive decline. The patient has been receiving Personal Care Services (PCS) 63 hours per week. Patient (via designee) requested increase of PCS to 84 hours per week.  

This patient has several chronic conditions most likely contributing to symptoms that affect her ability to perform daily activities. As people age, functional reserve decreases; and so when a new medical problem results in further functional decline, it becomes increasingly difficult to return to the prior level of function. Rehabilitation can help, but there can be limits to improvement due to the nature of the underlying medical conditions. The Uniform Assessment System (UAS) functional status report indicates the patient is totally dependent or needs maximal assistance with household related activities. Her daughters manage finances, medications and oxygen equipment. For ADLs, the patient needs maximal or extensive assistance for most activities, except eating and bed mobility (limited assistance). The daughters report the patient is unable to walk, use the commode or get out of bed without assistance; and she is so weak that she is unable to feed herself. 

The patient has dementia. The patient had cognitive decline following hospitalization including decline of memory; and decline of decision making for daily tasks to the point where patient's decisions are consistently poor/unsafe. It is not unusual for people with dementia who are hospitalized to experience mental status changes. It is likely that the patient's overall functional decline with daily activities is at least partly due to cognitive impairment. The patient's physical functioning declined following hospitalization, with reports noted of increased fatigue and weakness. The patient has heart failure and chronic obstructive pulmonary disease (COPD) which can lead to functional decline in this patient's age group as the diseases progress. Symptoms include chronic dyspnea and fatigue; and decreased endurance and activity tolerance for daily activities. 

Considering the patient's medical history and associated symptoms limiting her functional ability with ADLs and IADLs, it is medically necessary and in the patient's best interest to have a caregiver present to assist with daily activities. The patient's daughters are the informal caregivers. They are supportive, but are unable to provide assistance on a daily basis. Assistance from informal caregivers is voluntary as per New York State regulations for PCS. When informal caregivers are not available to provide care on a regular basis, then personal care services are indicated to assist the patient with daily activities as needed. The request for PCS is for 84 hours per week (12 hours per day). There is a concern as to how the patient can manage toileting, incontinence care and mobility around her home during the 12 hours when the aide is not present. It is not known whether the family has a plan for the other 12 hours per day. The maximum amount of hours that can be approved from this review is limited by the number of hours requested, i.e. 84 hour per week. 

The insurer did not act reasonably, or with sound medical judgement, or in the patient's best interest.

The carrier's denial of coverage for PCS 12 hours a day, 7 days a week is overturned. The medical necessity is substantiated.