Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Arthritis and lumbar radiculopathy.
Treatment:  Personal care services.

The insurer is denied coverage for personal care services.  The denial is reversed.  

This is a female has multiple medical conditions including arthritis and lumbar radiculopathy, which have caused long term pain and functional disability.  The patient lives alone.  She had been receiving personal care services (PCS) 6 hours per day, 5 days per week.  The insurer recently reduced services to 5 hours per day, 5 days per week.  The patient appealed the decision.  The insurer upheld the decision to reduce PCS to 25 hours per week.  The patient requested an external appeal.  The orthopedist's letter and the UAS include the following diagnoses:  osteoarthritis, bilateral shoulder arthritis, right knee arthritis, s/p left knee replacement, spinal stenosis, lumbar radiculopathy with bilateral leg weakness, sciatica right side, gait abnormality, osteoporosis, s/p L5-S1 transforaminal lumbar interbody fusion.  Orthopedist noted that patient cannot stand for more than 10-15 minutes.  Current treatment includes gabapentin, ibuprofen.

The patient's functional status as noted in the UAS indicates the following:  For IADLs, the patient needs maximal assistance with meal preparation, housework, and shopping, which is consistent with report of shoulder arthritis, back pain, lower extremity pain and weakness and difficulty standing for more than a few minutes.  She also needs extensive assistance for stairs (patient lives in 3rd floor walk-up apartment).  For ADLS the UAS indicates the patient needs limited assistance for bathing, lower body dressing, and transfer to toilet.  All other ADLs are noted as needing supervision, or independent with set up help.

Considering the patient has significant back and lower extremity symptoms (from arthritis, spinal stenosis, radiculopathy) and bilateral shoulder arthritis, the functional assessment for ADLs in the UAS does not appear to fully reflect the patient's impairments.  The comments from the nurse assessor note that the patient was observed to be in pain, with difficulty moving.  Patient had to periodically stop.  She could not complete the timed 4 meter walk.  It is noted that she needs assistance with daily activities when she has pain.  Gait is noted as unsteady.  She also has difficulty bending down and periodically needs assistance to stand up.

The insurer's denial letter indicates that an informal caregiver is willing and available to assist the patient after personal care service hours.  However, there is no documentation provided for this review identifying a specific informal caregiver, who has agreed to provide additional hours of assistance Monday-Friday if PCS hours are reduced.  If a change in the care plan is considered (i.e. reduction of PCS hours), then all aspects of the proposed plan needs to be documented; in this case, identification of the informal caregiver and specific hours of service the caregiver will provide.  It is unclear why the patient would still be appealing the insurer's decision to reduce PCS hours, if she had a reliable informal caregiver to provide assistance during the hours that she is losing from personal care services.  Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  In the absence of informal caregivers who can provide assistance for daily activities when needed the personal care services are indicated to provide the necessary care.

Personal Care Services 6 hours per day, 5 days per week, Monday to Friday, for a total of 30 hours per week are medically necessary.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Services 6 hours per day/5 days a week Monday to Friday, totaling 30 hours/week is substantiated.  The insurer's denial is reversed.