Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease.

Treatment: home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week.

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

The denial is overturned.


 
This elderly male has functional impairment associated with several medical conditions and needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). As per The Uniform Assessment for New York (UAS-NY), the patient lives alone. The patient's ex-wife and child are identified as informal helpers. The patient receives personal care services, provided by Consumer Directed Personal Assistance Program (CDPAP) 77 hours per week. The patient (via designee) requested increased personal care services to 84 hours per week, which was denied. 

The Uniform Assessment for New York (UAS-NY) indicates the patient is dependent on ordinary housework; he needs maximal assistance for meal preparation, shopping, transportation, and stairs; extensive assistance for managing medications and finances, and phone use. For activities of daily living (ADLs), the patient needs maximal assistance for bathing, personal hygiene, dressing the upper and lower body, toilet use; extensive assistance for walking, locomotion, transfer toilet, bed mobility, and eating.  

The patient has had Parkinson's Disease (PD) for more than 20 years. The effects of PD generally cause a progressive decline in the ability to perform daily activities. 

Regarding the patient's cognition, the neurologist's letter includes a diagnosis of Parkinson's dementia complex, but no details are provided. The patient's decision-making for daily tasks was described as modified independence (some difficulty in new situations). He was oriented to person, place, and time. He had short-term memory problems; he was noted as frequently forgetful. He was self-directing. 

The Uniform Assessment for New York (UAS-NY) reported the patient needs extensive assistance for toilet transfer; maximal assistance for toilet use (which includes incontinence care); and he has occasional urinary incontinence. 

The patient has a history of falls and remains at high risk for falls. 

Managed Long Term Care policy 16.07 states that plans must ensure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all the patient's care needs must be considered in the determination of the patient's personal care service hours. The patient's request to increase personal care service hours is not for stand-alone safety monitoring. The patient needs maximal or extensive (weight-bearing) assistance for safe, effective completion of activities of daily living (ADLs), due to his medical conditions and impaired functional status. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 84 hours per week services is substantiated.