Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure (CHF), diabetes, gout, hyperlipidemia, sleep apnea, spinal stenosis, and asthma

Treatment: home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 56 hours per week

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 56 hours per week

The denial is overturned

This geriatric patient has an extensive medical history associated with functional impairment and needs assistance for most daily activities. The Uniform Assessment (UAS) reports the patient lives with the spouse and other family members (one of the children and "other relative" were noted as living with the patient and providing informal help; the spouse is not mentioned as a caregiver). The patient receives personal care services (PCS) 28 hours per week. PCS was provided as Consumer Directed Personal Assistance Services (CDPAS). As per the insurer's final adverse determination (FAD) letter, the patient requested an increase of PCS to 56 hours per week.

NOTE: The patient's external appeal letter indicated the patient is requesting increase of personal care services to 70 hours per week. IPRO confirmed with insurer that PCS 56 hours per week was requested and denied. IPRO informed the patient who expressed understanding that the appeal is for 56 hours.

The most recent UAS provided was reviewed. The functional status report for Independent Activities of Daily Living (IADLs) indicates the patient was dependent for ordinary housework; the needed maximal assistance for meal preparation, stairs, shopping, transportation; setup help for phone use, managing medications and finances. For Activities of Daily Living (ADLs), the patient needed extensive assistance for bathing, dressing lower body, transfer toilet, toilet use, walking, locomotion; limited assistance for personal hygiene, dressing upper body; setup help for bed mobility, eating.

Comparison of the previous UAS with the recent UAS indicates a decline in function for several ADLs occurred as follows (older UAS is noted first; recent UAS is in parentheses):

Personal hygiene: setup help (limited assistance); dressing lower body: limited assistance (extensive assistance); walking, locomotion: setup help (extensive assistance); toilet transfer, toilet use: limited assistance (extensive assistance).

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. All the patient's care needs throughout the day must be considered in the determination of personal care service hours. Increase of PCS hours would not be for stand-alone safety supervision. The patient needs additional assistance for proper, safe and timely completion of ADLs and IADLs.

Considering the patient's medical history and functional impairments, caregiver assistance for ADLs and IADLs is medically necessary at various times throughout the day to help maintain the patient's health and safety, and help prevent adverse events, such as falls/household accidents; skin damage due to inadequate cleaning with toileting/incontinence; hypoglycemia; dehydration. 

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal helpers are unable to assist with necessary care on a consistent basis, then personal care services are indicated to assist with ADLs and IADLs when needed throughout the day.

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 56 hours per week is substantiated.