Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, hypertension, cognitive impairment and osteoarthritis

Treatment: Home care/personal care Home Health Care (HHC) - Level 2 personal care services (PCS), per 15 minutes increase to 84 hours/week

The insurer denied coverage for home care/personal care HHC - Level 2 PCS, per 15 minutes increase to 84 hours/week.

The denial is overturned.

This elderly patient has significant functional impairment associated with her medical conditions and needs assistance with all daily activities. The Uniform Assessment System (UAS) reported the patient lives with her husband (UAS noted the husband was present and assisted with patient's UAS). 

The most recent UAS provided was reviewed. The functional status report for instrumental activities of daily living (IADLs) indicates the patient was totally dependent for ordinary housework; she needed maximal assistance for meal preparation, managing finances, shopping, transportation, stairs; she needed extensive assistance for managing medications, phone use. For activities of daily living (ADLs), the patient needed maximal assistance for bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use; extensive assistance for personal hygiene, dressing upper body, bed mobility, eating.

The patient has Parkinson's disease (PD). Motor symptoms of PD include tremor, bradykinesia, rigidity, postural instability, unsteady gait; all of which can adversely affect ability to perform daily activities. Non-motor symptoms include autonomic dysfunction (blood pressure changes including orthostatic hypotension; bowel and bladder dysfunction); cognitive impairment (memory impairment, dementia); mood disorders (anxiety, depression). Other symptoms associated with PD include dizziness, fatigue, pain, and sleep disturbances. 

Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. These care needs must be considered in the determination of the patient's personal care service (PCS) hours. It is medically necessary for the patient to have a caregiver throughout the day to ensure all ADLs/IADLs are completed properly and safely, including routine tasks and activities that occur at unscheduled and/or recurring times of the day (toileting, incontinence care, eating, drinking, medications, mobility). Assistance is necessary to help maintain skin integrity, decrease occurrence of falls, facilitate safe, adequate food and fluid intake, ensure medication compliance, and to help with pain management.

The UAS identified the patient's son as an informal helper, but his current availability is not known. Considering the request for an increase of PCS to 84 hours/week, it is reasonable to conclude there are no informal helpers who can provide assistance for the additional hours requested. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for PCS. When informal caregivers are unable to provide care on a consistent basis, then PCS are indicated to provide necessary assistance for daily activities. The patient will benefit from increase of PCS to 84 hours/week, 12 hours/day as she needs assistance with all ADLs/IADLs from morning to evening.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for home care/personal care Home Health Care (HHC) - Level 2 PCS, per 15 minutes increase to 84 hours/week is substantiated.