Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, chronic arthritis, bilateral primary osteoarthritis of the knee, polyosteoarthritis, pilonidal cyst, glaucoma, urinary incontinence, vertigo, dizziness and giddiness, gastritis, gastroesophageal reflux disease, memory loss, depression and sleep issues.
Treatment: Home care / personal care HHC - level 2 personal care services of 84 hours per week.
The insurer denied coverage for home care / personal care HHC - level 2 personal care services of 84 hours per week.
The denial is overturned.

This patient is a female with impaired functional ability with daily activities due to various medical conditions. She lives with her daughter, son-in law and grandchildren. She has been receiving personal care services as Consumer Directed Personal Assistance Services (CDPAS) 35 hours per week. The Uniform Assessment System (UAS) indicated the patient's daughter was the CDPAS aide. In the UAS, there was no specific identification of CDPAS aide. Nursing comments noted family was assisting with activities of daily living (ADL) and Instrumental Activities of Daily Living (IADLs). The advocate's report indicated the patient receives personal care services late afternoon to evening and she does not have assistance with morning dressing and with breakfast and lunch. This description suggests that the patient is alone during the day until the aide arrives late afternoon. The orthopedist's letter recommended increase of personal care services; noting the patient lives with her daughter, who has other family responsibilities. Request was made to increase personal care services (provided as CDPAS) to 84 hours per week, which was denied. An external appeal was requested.

The patient is receiving personal care services as CDPAS. As noted, it is not clear who is providing care as the CDPAS aide, and whether there will be a change if hours are increased. The assignment of CDPAS aide is beyond the scope of this review. The determination of personal care hours is dependent on patient's need for assistance with daily activities. The current availability of informal caregivers is not known; however, considering there is a request for personal care services 12 hours per day, it is reasonable to conclude that informal caregivers are unable to provide the necessary help with daily activities during this period of time each day. It appears the family is able to provide informal support during the other 12 hours of the day (as the patient may still need assistance with toileting, getting out of bed at night). As per NYS(New York State) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care when needed on a regular basis, then personal care services are indicated to provide necessary assistance with ADLs and IADLs when needed throughout the day. The available records support the need for a caregiver during all daytime/evening hours (until the patient goes to bed each night) to assist with all scheduled activities over the course of the day (all meals; morning and evening ADLs, other household tasks specific to the patient's needs) and unscheduled activities that occur at various and unpredictable times throughout the day (transfers, walking around the home, toileting, incontinence care).

Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, 84 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Home Care / Personal Care HHC - Level 2 Personal Care Services of 84 hours per Week is reversed. Medical necessity is substantiated.