Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular dementia.

Treatment: Personal Care Services Level 2 for a total of 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 for a total of 12 hours per day, 7 days per week for a total of 84 hours per week.

The denial is overturned. 

This is a female patient with a diagnosis of vascular dementia who has had cognitive decline associated with functional impairment and need for assistance with most daily activities. The Uniform Assessment System (UAS) report indicated the patient lives with her daughter who provides assistance with daily activities after work. It was reported that the patient lives alone, and the daughter visits every 2 weeks; she does not provide daily care. The patient is currently approved for personal care services (PCS) 42 hours per week. The patient (via designee) requested increase of PCS to 84 hours per week, which was denied by the insurer. 

The UAS report indicates the patient is totally dependent on caregivers for housework and needs maximal assistance for most other instrumental activities of daily living (IADLs), except transportation and stairs (extensive assistance). The patient needs extensive assistance for bathing; limited assistance for personal hygiene, dressing and toilet use; supervision for walking/locomotion, toilet transfer; and set up help for eating and bed mobility. Regarding activities of daily living (ADLs), the daughter reported that the patient needs assistance with ADLs due to a decline in mental status. As dementia progresses, the need for assistance with ADLs may be related to loss of ability to recognize and remember what to do for various daily tasks. Impaired memory and poor judgment/safety awareness increases the risk of falls and other accidents if the patient attempts to perform daily activities without supervision and assistance. Providing safety precautions during ADLs care is part of the scope of care for personal assistance services. 

The available records identify symptoms that probably affect the patient's physical function with daily activities. The UAS indicates the patient has osteoarthritis; specific joints are not noted. The patient does not have the cognitive ability to safely manage most of her daily activities. She needs assistance with IADLs and ADLs to maintain her health and safety in her home. It is medically necessary and in the patient's best interest for her to have a caregiver present to assist with ADLs and IADLs as needed throughout the day. The patient has no informal caregivers who can provide care on a regular basis. As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are not available to provide care on a consistent basis, then personal care services are indicated to assist with daily activities when needed throughout the day.

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

The carrier's denial of coverage for the requested Personal Care Services Level 2 for a total of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. The medical necessity is substantiated.