Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, coronary artery disease (CAD), congestive heart failure (CHF), atrial fibrillation, peripheral vascular disease (PVD), hyperlipidemia

Treatment personal care services, level 2, 10 hours per day, 5 days per week, for a total of 50 hours per week

The insurer denied coverage for personal care services, level 2, 10 hours per day, 5 days per week, for a total of 50 hours per week

The denial is overturned

This male has extensive medical history associated with functional impairment that limits his ability to perform daily activities. As per UAS (Uniform Assessment System) the patient receives personal care services (PCS) 7 hours per day, 5 days per week, total of 35 hours per week. The UAS appears to indicate the patient does not have informal caregiver assistance on weekdays, but he has some informal help with ADLs (activities of daily living) and IADLs (instrumental activities of daily living) on weekends (full description of time and specific services not noted). Patient requested increase of PCS services to 10 hours per day, 5 days per week, total 50 hours per week, which was denied. An external appeal was requested.

The patient's functional status indicates patient needs maximal assistance for most IADLs; except phone use and managing finances (limited assistance); managing medications (supervision). For ADLs, he needs extensive assistance for bathing, lower body dressing, walking, locomotion, transfer toilet, toilet use; limited assistance for personal hygiene, upper body dressing; supervision for bed mobility and eating. Comparing two UAS reports, there is a significant change for some ADLs.  It was noted that the patient needed limited assistance for walking, locomotion, transfer toilet, toilet use. The reported patient needs extensive (weight-bearing) assistance for these ADLs. 

Considering the patient's medical history and functional impairments, caregiver assistance for ADLs and IADLs is medically necessary every day at various times throughout the day for the patient's health and safety. Without adequate assistance, the patient is at risk for adverse health and safety events, including falls/household accidents; skin damage due to inadequate cleaning with toileting/incontinence; decreased food/fluid intake; hypoglycemia. 

The UAS reports the patient's granddaughter provides some assistance on weekends (noted as Saturday and/or Sunday), but the amount of time, and which ADL services she provides are not noted. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unable to provide care on a regular basis, then personal care services are indicated to provide necessary assistance for daily activities, including ADLs that occur at various and unscheduled times throughout the day. Considering the patient requested PCS 10 hours per day 5 days per week, it is reasonable to conclude that there are no informal caregivers who can provide care for that amount of time 5 days per week. However, it is unclear as to whether the patient receives adequate care the other two days of the week. There is also some concern about the patient's care needs during late evening and night hours, including toileting related tasks, transfers, walking. 

The maximum number of hours that can be recommended for approval from this review is limited by the number of hours requested.
 
Allocation of hours should be determined with the patient to best meet his needs. If the patient is not receiving adequate informal care on the weekends, it is suggested that some PCS hours are allocated for every day of the week to at least ensure assistance with some ADLs and meals each day. 

Recommendation is given to approve Personal Care Services, level 2, 50 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 services, level 2, 10 hours per day, 5 days per week, for a total of 50 hours per week is overturned. Medical Necessity is substantiated.