Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Osteoarthritis, and Vision loss.

Treatment: Home Care/ Personal Care HHC - Level 2 Personal Care Services (PCS), per 15 minutes increase to 84 hours per week.

The insurer denied coverage for Home Care/ Personal Care HHC - Level 2 PCS, per 15 minutes increase to 84 hours per week.

The denial is overturned.

This is a female patient who lives alone and requires help with most daily activities. The patient has been receiving Personal Care Services (PCS) 56 hours per week. The patient has additional aide services (privately hired by family) for hours not covered by PCS. The aide's affidavit explained that she and other aides are assigned for different periods of time during the week that in total provides 24 hour live-in care. The daughter's affidavit and the physician's letter indicate the patient needs 24 hour care. There is a note in the external appeal application which indicates the patient needs 24/7 care. However, the insurer's final adverse determination notice indicates the request for increase of PCS was for 84 hours per week, which was denied. The daughter requested an external appeal. 

The most recent Uniform Assessment System (UAS) report was provided for review. The functional status report indicated the patient was totally dependent or needed maximal assistance for most instrumental activities of daily living (IADLs), except stairs (extensive assistance). For activities of daily living (ADLs), the patient needed maximal or extensive assistance for most ADLs except walking/locomotion (limited assistance); eating (supervision); bed mobility (independent setup help). Based on the available records, it appears the patient's functional decline is the result of both cognitive and physical impairments from various medical conditions, including the following: dementia, osteoarthritis, and vision loss.   

Considering the patient's medical history, symptoms, and functional status, it is medically necessary for the patient to have assistance for all daily activities. The patient needs assistance with IADLs and ADLs that occur at various scheduled and unscheduled times throughout the day and night. Without adequate caregiver support through the day and night, the patient is at risk for adverse medical and safety events, e.g. falls/injury, weight loss, malnutrition, skin damage from incontinence. In the insurer's final denial letter, it was noted that additional PCS hours (beyond 56 per week) would be for safety monitoring, which is not a covered benefit. 

The patient needs assistance with ADLs through the day and night. This is not stand-alone safety supervision. The patient needs assistance for ADLs that occur at various times of the day and night. In addition, the patient's behavior is unpredictable due to dementia, and so when she needs assistance unexpectedly at various times during the day and night; she needs a caregiver to provide physical support for mobility and other ADLs. Providing safety precautions during ADL care is part of the scope of practice for personal care services.

Assistance from informal caregivers is voluntary as per New York State regulations for PCS. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at various and unscheduled times through the day and night.

The maximum amount of hours that can be approved from this review is limited by the number of hours requested, as documented in the insurer's final adverse determination notice; in this case 84 hours per week. 

The health plan did not act reasonably with sound medical judgement. 

The medical necessity for the requested Home Care/ Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week is substantiated.  The insurer's denial is overturned.