Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary heart disease, diabetes, cerebrovascular accident (CVA), hemiplegia, hypertension, and hyperlipidemia
Treatment: personal care services, 12 hours a day, 7 days a week for a total of 84 hours a week
The insurer denied coverage for personal care services, 12 hours a day, 7 days a week for a total of 84 hours a week
The denial is overturned

 
The patient is a male with a past medical history that includes coronary heart disease, diabetes, cerebrovascular accident (CVA), hemiplegia, hypertension, and hyperlipidemia. Per the telephonic Uniform Assessment for New York (UAS-NY) the patient lives alone. The patient reported having a few falls at home. The patient is alert and oriented (A+O) times 3. The patient can activate a personal emergency response system (PERS). The patient requires maximal assistance with meal preparation, housework, stairs, shopping, transportation, bathing, dressing lower body, walking, and toileting. The patient requires extensive assistance with managing medications, personal hygiene, and dressing upper body. The patient's activities of daily living (ADL) status has declined within the past 90 days.. The patient had two or more falls within the last 90 days. The patient lives alone. There were no hospitalizations within the last 90 days. 

Reckrey, J. M., Tsui, E. K., Morrison, R. S., Geduldig, E. T., Stone, R. I., Ornstein, K. A., & Federman, A. D. (2019), "Older adults prefer to remain living at home even with the substantial functional impairment that is common in the last years of life.(1,2) This fact, in combination with growing evidence of the cost effectiveness of community-based long-term care, is driving interest in shifting the locus of long-term care from institutions to the community.(3-6) Paid caregivers (e.g. home health aides, personal care attendants, and other direct care workers) will increasingly be needed to provide the hands-on care that supports this shift.(7) The large and growing workforce of paid caregivers spends hours each day with patients with functional impairment and witnesses their chronic health needs, changes in health status, and psychosocial stressors. As a result, paid caregivers have the potential to serve as valuable members of patients' multidisciplinary health care team and influence health outcomes."

"The activities of daily living (ADLs) is a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. The term activities of daily living was first coined by Sidney Katz in 1950. ADL is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Measurement of an individual's ADL is important as these are predictors of admission to nursing homes, need for alternative living arrangements, hospitalization, and use of paid home care. The outcome of a treatment program can also be assessed by reviewing a patient's ADLs." (Edemekong, P. F. et al. 2022).



Based on the above, the insurer's denial must be overturned. 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 personal care services, 12 hours a day, 7 days a week for a total of 84 hours a week is substantiated.