Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, congestive heart failure (CHF), thrombosis of deep veins of lower extremities, a displaced fracture of the right femur, gastroesophageal reflux disease (GERD), and hyperlipidemia

Treatment: Personal care worker (PCW) services 7 days a week, 24 hours per day, live in; 91 hours per week

The insurer denied coverage for personal care worker (PCW) services 7 days a week, 24 hours per day, live in: 91 hours per week
The denial is overturned

This patient has experienced functional decline associated with various medical conditions, including multiple fractures due to a fall earlier this year. The records indicate the patient fell and she was hospitalized (left femur fracture, s/p left hip hemiarthroplasty), transferred to a rehabilitation facility, then was discharged home. Prior to these events, the patient lived alone, and relied on personal care worker (PCW) services for assistance with daily activities. Following the hip fracture, the patient (via designee) requested an increase of PCW services to 24 hours per day live-in, which was denied; but the insurer increased PCW services to 63 hours per week. 

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple medical conditions. Other factors include economic and social circumstances, (e.g., caregiver support). In addition to her chronic medical problems, the records indicate the patient had multiple fractures due to a fall. It is expected that this acute event would have adversely affected performance of most daily activities as it affects her upper and lower extremity function. Accelerated periods of functional decline can occur in response to new/acute medical events. 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. 

As per her most recent UAS (uniform assessment system) form, the patient has a h/o (history of) pain in both shoulders; cause is not noted, but this most likely has limited her ability with most daily activities that require upper extremity function (e.g., bathing, dressing, personal hygiene, toileting, household tasks). This was exacerbated with the recent fracture of her left humerus and clavicle. Chronic pain appears to be a significant issue. The UAS included comments from the daughter reporting that she would leave prepared meals in the freezer for her mother, but her mother would usually stay in bed if she was in too much pain (indicating she skipped meals). Pain management is another problem. With consideration of the patient's recent cognitive decline and limited physical function, it is not clear how the patient can safely and reliably provide self-help for pain control when she is alone, either with medication and/or repositioning in bed (rehab notes indicate the patient needs significant help with bed mobility).

As per NYS (New York State) regulations for personal care services, in order to qualify for 24-hour live-in services, the patient's need for assistance must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep in an 8-hour sleep period per day. There are no nighttime activity records provided for review to help determine the frequency of the patient's nighttime ADL (activities of daily living) needs. However, it is apparent from the available information that the patient needs assistance for daily activities beyond 9 hours per day (current PCW services) as previously reviewed in this report. 

Recommendation is given to approve Personal Care Worker services, 7 days per week, 24 hours per day live-in, 91 hours per week.

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 personal care worker (PCW) services 7 days a week, 24 hours per day, live in; 91 hours per week is overturned. Medical Necessity is substantiated.