Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease

Treatment: Increase in personal care assistance services of 7 days per week, 10 hours per day for a total of 70 hours per week

The insurer denied coverage for an increase in personal care assistance services of 7 days per week, 10 hours per day for a total of 70 hours per week.

The denial is overturned. 

This is a female patient with a medical history of Alzheimer's disease, chronic pain, weakness, essential primary hypertension and Vitamin D deficiency. Per Uniform Assessment System (UAS) documentation, the patient requires maximum assistance for meal preparation, ordinary housework, managing finances, managing medications, managing stairs, shopping and transportation. The patient requires extensive assistance with phone use, bathing, personal hygiene, dressing, walking, locomotion, toilet transfer and toilet use. The patient needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient is incontinent at times. The patient ambulates with a walker in her home and uses a wheelchair when outside. The patient cannot be left alone safely. The patient's son is involved in her care, and he assists her during the night time. An increase in personal care assistance services of 7 days per week, 10 hours per day for a total of 70 hours per week is being requested.

As per the New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016: 
(a) Definitions and scope of services.
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

In this case, the patient has dementia, incontinence and except for independent bed mobility needs extensive assistance with her ADLs. The patient has lost formal daytime caregiver (daycare) due to COVID-19, and has family only at night-time. The patient has unscheduled needs and cannot be left alone safely. Based on the review of the patient's medical records, the patient is at risk for injury and sores due to dementia, incontinence and poor mobility. The patient no longer has a daytime caregiver who can bridge between 4 hours/day and family assistance even up to 12 hours/day. The patient's insurer did not take into account the lack of daytime services in a patient at risk for falls, other problems due to poor mobility, incontinence and dementia. Thus, increase in personal care assistance services of 7 days per week, 10 hours per day for a total of 70 hours per week is considered medically necessary for this patient. 

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

Based on the above, the medical necessity for the requested increase in personal care assistance services of 7 days per week, 10 hours per day for a total of 70 hours per week is substantiated. The insurer's denial should be overturned.