Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, osteoporosis, hyperlipidemia, fibromyalgia, hypertensive heart disease.

Treatment personal care services, level 2, at 12 hours per day, 7 days per week for a total of 84 hours per week.

The insurer denied coverage for personal care services, level 2, at 12 hours per day, 7 days per week for a total of 84 hours per week.

The denial is overturned.

This patient has functional impairment associated with several medical conditions, primarily related to chronic pain. She has two grandsons who are supportive but are unable to provide daily assistance on a regular basis. The patient depends on personal care services (PCS) for assistance with ADL [activities of daily living] and IADL [instrumental activities of daily living]. She had been receiving PCS [personal care services] 20 hours per week, 4 hours per day, 5 days per week. 

Regarding the patient's cognitive status, the UAS (Uniform Assessment System) describes the patient's decision-making ability for daily tasks as modified independence (some difficulty in new situations); occasional forgetfulness, but no significant memory impairment identified; oriented to person, place, and time. Patient needs occasional reminders for medications. It appears the patient's need for assistance with daily activities is primarily due to physical functional impairment; however, forgetfulness can affect attention to safety precautions and may increase risk of falls and household accidents.

An important change in functional status was noted in the comparison of the two UAS reports. The patient needed only supervision for toilet transfer; and was reported as needing extensive assistance in a later UAS. The patient's need for weight-bearing assistance with toilet transfer raises concern for falls in the bathroom (when she is alone) which is associated with increased risk of injury. It is not clear how the patient manages to transfer on/off the toilet without help during the 19 hours she is alone each day. Regarding toilet use, the patient has shoulder and hand pain which can interfere with proper cleaning/hygiene. It is also likely she has difficulty with clothing adjustment before and after using the toilet (needs extensive assistance for lower body dressing).

Based on the patient's medical history and functional status, it is medically necessary for the patient to have assistance with daily activities. This includes IADLs; routine ADLs (including bathing daily; personal hygiene and dressing morning and evening); and ADLs that occur at various unscheduled times of the day (e.g., all toileting related tasks, transfers and ambulation). 

MLTC (Manage Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all the patient's care needs must be considered in the determination of the patient's personal care service hours.

It was reported in the UAS that the patient has two grandsons who are supportive but are unable to provide daily assistance with ADLs and IADLs. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. Therefore, the patient depends on personal care services for assistance with daily activities, including housekeeping tasks, meal preparation and service, routine ADLs, and ADLs that occur at various unscheduled times of the day.  The patient will benefit from personal care services for a longer period of time each day to accommodate most of her personal care needs from morning until she gets ready for bed at night. 

Personal Care Services level 2, 12 hours per day, 7 days per week, total 84 hours per week are medically necessary.

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 Services, Level 2, at 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical Necessity is substantiated.