Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Arthritis, Osteoporosis, Hypertensive heart disease with heart failure, Metastatic cancer.
Treatment:  Personal Care Services, 24 hours per day (live-in), 7 days per week, 91 hours total.

The insurer denied coverage for Personal Care Services, 24 hours per day (live-in), 7 days per week, 91 hours total.  The denial is overturned.

This is a male patient with an extensive medical history that includes osteoporosis, gait abnormality, dizziness, generalized muscle weakness, a history of falling, coronary heart disease, hypertensive heart disease with heart failure, atrial fibrillation, type 2 diabetes mellitus, and metastatic cancer.  He was hospitalized due to nephrolithiasis complicated by cardiac problems, and discharge instructions included home health services.  The health plan approved Personal Care Services (PCS) 11 hours per day, 7 days per week, 77 hours total.  The patient (via designee) requested an increase of PCS to 24 hours per day (live-in), 7 days per week, 91 hours total; this was denied.   

This patient has an extensive medical history and substantial functional impairment, requiring a high level of assistance with most daily activities.  According to the functional assessment from the Uniform Assessment System (UAS) documentation, the patient is totally dependent on caregiver assistance for most instrumental activities of daily living (IADLs), except maximal or extensive assistance for finances, medications and phone use.  The patient needs maximal or extensive assistance for all activities of daily living (ADLs) except eating (limited assistance).  Regarding the patient's cognition, decision making for daily tasks in certain situations is noted as poor or unsafe.  The patient has a short term memory problem and periods of confusion.  It is likely that cognitive impairment adversely affects the patient's ability with IADLs; ADLs may also be affected by cognitive decline. 

The patient has metastatic cancer with various signs and symptoms consistent with advanced cancer, including weakness, fatigue, and pain.  Additional medical problems include arthritis as another source of pain and heart failure probably contributing to fatigue, dyspnea, and decreased endurance.  Considering the patient's medical conditions and substantial functional impairment, it is medically necessary for the patient to have a caregiver present to provide assistance with all daily activities, including ADLs that occur at various times throughout the day and night: toileting and incontinence care, out of bed mobility (transfers, walking, locomotion), bed mobility/repositioning on a regular basis for pressure relief. 

The UAS does not identify any informal caregivers, who can provide the patient with assistance for IADLs and ADLs for extended periods of time each day.  Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  When informal caregivers are not available to provide care when needed on a consistent basis, then PCS is indicated to provide the necessary assistance with IADLs and ADLs as needed throughout the day and night.  As per NYS regulations for live-in aide services, the patient's need for assistance should be sufficiently infrequent to allow a live-in aide to have 5 uninterrupted hours of sleep each day. 

The maximum amount of hours that can be approved from this review is limited by the amount requested, i.e., 24 hours live-in services, which is 13 hours per day, 7 days per week, total of 91 hours per week.  At this time, it is medically necessary and in the patient's best interest to increase PCS to 24 hours live-in, 91 hours per week.

The health plan did not act reasonably with sound medical judgement in the best interest of the patient.

The carrier's denial of coverage for PCS 24 hours a day (live-in), 7 days a week is overturned.  The medical necessity is substantiated.