Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)

Treatment personal care services of 8-12 hours per day, 7 days per week for a total of 84 hours per week

The insurer denied coverage for personal care services of 8-12 hours per day, 7 days per week for a total of 84 hours per week.

The denial is overturned.

This is the case of a female who has extensive medical history associated with functional impairment and needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives alone. She has limited informal help and depends on personal care services (PCS) for assistance with all ADLs and most IADLs. The patient currently receives PCS 35 hours per week (5 hours per day). 

The most recent New York State Department of Health's Uniform Assessment System (UAS-NY) provided for review. The functional status report indicates the patient is totally dependent or needs maximal assistance for most IADLs; except managing finances and equipment (extensive assistance); managing medications, phone use (limited assistance). For ADLs, the patient needs extensive assistance for all toileting related tasks, bathing, lower body dressing, walking, locomotion; limited assistance for personal hygiene, upper body dressing, bed mobility; setup help for eating.

The Uniform Assessment System (UAS) reports the patient does not have urinary incontinence. However, there are some risk factors that may result in episodes of incontinence. As noted, she takes diuretics which increases frequency of urination. The patient has impaired mobility, and when she needs to reach the bathroom or commode quickly, it is likely there are times when the effort is limited by pain, weakness, fatigue, shortness of breath. A common cause of incontinence in older people is delay in reaching a toilet or commode in time (i.e., functional incontinence), often due to difficulty with transfers and walking. When the patient does not have caregiver assistance, mobility is more difficult, and episodes of incontinence may occur due to increased time needed to reach the toilet.  When there is an immediate need to reach the toilet, transfers and walking are often done in haste and with less regard for safety, which also increases the risk for falls. 

The need to use the toilet is an unplanned, recurring activity throughout the day. The aide is present 5 hours per day, and the UAS indicates there are no informal caregivers for ADL assistance. The available records support the need for caregiver assistance for a more extended period of time each day to assist with toileting related care.

For other routine ADLs, the patient needs assistance daily with bathing; and morning and evening for dressing and personal hygiene. The aide's daily schedule is not noted, but unless the 5 hours are split, the aide is present for either morning or evening ADLs. Split hours for morning and evening would leave the patient without assistance for most of daytime hours. Regarding meals, the aide is present for 5 hours per day; and so only two meals can be served and assisted by the aide. It is not clear how the patient manages her third meal each day when she is alone. The patient needs maximal assistance for meal preparation. Even if the aide leaves meals in the refrigerator, and even if they are all cold platters (no re-heating needed), transfer of food from the refrigerator to the table is a safety risk. It is not known if she can maneuver the wheelchair in the kitchen (many apartments have small kitchens). If she needs to walk to the kitchen, even with a tray on her walker, transfer of food to a table is an unsafe situation. If she spills food or fluids on the floor, this could result in a slip and fall accident. 

There is some concern about the patient's need for assistance during the evening/night hours, especially for toileting and out-of-bed mobility. It is not known if the family has other arrangements for nighttime assistance. The patient will benefit from having caregiver assistance for daily activities from morning until evening when she is most active and in need of more frequent care. 

Personal Care Services 12 hours per day, 7 days per week, total of 84 hours per week are medically necessary. The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient. 

The insurer's denial of coverage for the requested Personal Care Services of 8-12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical necessity is substantiated.