Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis, fatigue, tremor, dementia with other behavioral disturbance, depression, anxiety disorder, gait and mobility abnormalities, chronic pain, incontinence without sensory awareness.
Treatment:  Home Care/Personal Care HHC (home health care) - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift).

The insurer denied coverage for Home Care/Personal Care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift).  The denial is overturned.

This elderly female has physical and cognitive impairment associated with various medical conditions and needs help with all daily activities. There is some inconsistency in the records regarding her living situation. The Uniform Assessment System (UAS) indicates the patient lives alone on the 1st floor of a private house. The previous UAS indicates the patient lives with her son and daughter-in-law in a private house, noting that patient lives on the 1st floor. The letter from the community friend reports the patient lives alone. The care plan indicates the patient and her son have the same home phone number, so possibly the patient lives in the same house with family but she has a separate apartment on the 1st floor. The patient's son is identified as an informal helper (the same son that is reported in the UAS as residing with the patient). It is noted that the son's availability for informal help is limited due to work obligations and relocation (unclear if relocation refers to work or home). The patient mostly depends on personal care services (PCS) for help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She had been receiving personal care services (PCS) 63 hours per week. The patient (via designee) requested an increase of PCS to 24 hours per day split shift, which was denied; but PCS was increased to 24 hours per day, live-in.

The most recent UAS provided for review was done. The functional status report for IADLs indicated the patient was totally dependent for meal preparation, ordinary housework, managing finances, shopping, stairs, and transportation; she needed maximal assistance for managing medications, phone use, and equipment management. For ADLs, the patient was totally dependent for locomotion; she needed maximal assistance for bathing, personal hygiene, dressing upper and lower body, walking, transfer toilet, toilet use; limited assistance for eating, and bed mobility.

Based on information provided for review, the patient's ADL and IADL care needs include housekeeping tasks; meal preparation; assist with medications (routine and prn (as needed), eating, bathing, dressing, personal hygiene, and unscheduled and/or recurring ADLs during the day and night (toileting/incontinence care, repositioning, transfers, out-of-bed mobility). Considering the frequency and level of care the patient needs for ADLs and IADLs, there does not appear to be a consistent predictable time period each day when a live-in aide can have 5 hours of uninterrupted sleep. The community friend's report that the patient calls out for help and wakes up the live-in aide confirms that live-in services are not compatible with the patient's care needs, and not in compliance with NYS (New York State) regulations for live-in aide services. 

With 24 hour split shift services in place, the aides can provide details of the patient's care needs day and night which can help with the next assessment. At this time, based on the information provided for review, the patient's daily care needs can be best served with 24-hour continuous (split shift) services.

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 Home Care/Personal Care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is substantiated.