Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD) with continuous oxygen at 3 liters via nasal cannula

Treatment: personal care services of 13 hours a day, 7 days a week for a total of 91 hours per week

The insurer denied coverage for personal care services of 13 hours a day, 7 days a week for a total of 91 hours per week

The denial is overturned

The patient is a woman with a past medical history of chronic obstructive pulmonary disease (COPD) with continuous oxygen at 3 liters via nasal cannula, coronary heart disease, dementia, stroke, depression, gastroesophageal reflux disease (GERD), Lyme disease, rheumatoid arthritis, hypothyroidism, uterine cancer, right artificial knee joint and chronic peripheral venous insufficiency. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her aide were present on the call. The patient resides with her disabled spouse who is unable to assist her after the aide's hours. The patient also does not have any family members in her vicinity. Her functional status has declined after a fall accident one month ago but with no injuries. The patient's overall self-sufficiency has deteriorated compared to her status 90 days ago. She reported that she stays in her wheelchair most of the time, and she has difficulty ambulating. 

Needs are: 

-	Total dependence for ordinary housework and locomotion;
-	Maximal assistance for meal preparation, shopping, stairs, transportation, bathing, dressing her lower body, walking, toilet transfer and toilet use;
-	Extensive Assistance for equipment management, personal hygiene, dressing her upper body and bed mobility;
-	Limited assistance for managing finances, managing medications, phone use and eating;
-	Cognition: Mild impairment. 
-	Continence: There is urinary but no bowel incontinence. She uses pull ups, and the aide assists her with changing the pull ups, which is approximately 4 to 5 times per day.

The patient uses a wheelchair for locomotion indoors. She has a history of pressure sores. 

An increase to personal care services of 13 hours a day, 7 days a week for a total of 91 hours per week is being requested.

In a letter, her Medical Doctor (MD) notes that her health is declining and she needs more evening services due to problems with mobility and toileting. 

The patient has forgetfulness and physical frailty that has resulted in her needing extensive-maximal assistance in all functions. She is incontinent of urine and already has had pressure damage. She needs frequent changes of pull-ups that she cannot do by herself. Further durable medical equipment (DME) is suggested for safety in bed and toileting but she needs assistance in bed, with transfers, with locomotion and toileting. 

The provision of diapers and alternate pressure beds is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers"- changing diapers regularly and positioning are also necessary. 

She is not able to implement further use of continuing medical education (CME), as she is already severely dependent.

Additional hours would not be for safety or supervision only. The request is approved. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's assessment of her needs.		
	
The insurer's denial of coverage for the requested Personal Care Services of 13 hours a day, 7 days a week for a total of 91 hours per week is reversed. Medical necessity is substantiated.