Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, Hypertension, Hyperlipidemia, Coronary Artery Disease, Dementia and memory Loss.
Treatment: Personal care services, 24 hours a day (live-in), 7 days a week.
The insurer denied coverage for personal care services, 24 hours a day (live-in), 7 days a week.
The denial is overturned.

The patient is a female with a past medical history of diabetes, hypertension, hyperlipidemia, coronary artery disease status post stent placement and carotid artery plaque. The patient also has dementia and memory loss, which is likely Alzheimer's disease. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her daughter- in-law were present on the call. The patient lives alone in a three bedroom apartment in a private house. She is totally dependent for meal preparation, ordinary housework, managing finances, shopping and transportation. The patient needs maximum assistance with stairs, bathing, dressing her lower body and toilet use. The patient has frequent bladder incontinence and occasionally bowel incontinence, and she uses pull ups. She has some bladder awareness. She needs extensive assistance with managing medications, phone use, personal hygiene, dressing her upper body, toilet transfer, walking and locomotion. The patient uses an assistive device for locomotion indoors. The patient needs limited assistance with eating. She needs supervision with bed mobility. The patient fell in the nighttime while she was on her way to the bathroom. She also fell the morning due to tripping. The patient's daughter-in-law also stated that the patient almost fell one morning but she caught her right away. There were no major injuries reported. The patient's son and daughter-in-law are involved in her care and take turns to provide assistance during hours when there is no personal care aide available. An increase to personal care services, 24 hours a day (live-in), 7 days a week is being requested.

The insurer has denied coverage for the personal care services, 24 hours a day (live-in), 7 days a week. In their Final Adverse Determination, they stated the request to increase services was denied because it was not medically necessary. The insurer stated the tools, assessments and the New York State Department of Health Guidelines, Title: Section 505.14-Personal Care Services did not support the medical necessity of the request. The insurer also reviewed the patient's care management record. They determined the patient's care needs can be met with her current services of 9 hours a day, 7 days a week for a total of 63 hours per week, in addition to the items in her home. She needs safety monitoring but not in the performance of tasks, and that is not covered. She has no nighttime needs. 

An advocate is appealing on behalf of the patient. She details the patient's needs and notes that the patient qualifies for 24-hour care. The patient's doctors noted the need for 24-hour care. Activity logs show at least one bathroom use/night.

At issue is the medical necessity of personal care services, 24 hours a day (live-in), 7 days a week.  The patient has severe and worsening dementia and needs assistance with all functions as noted above except for bed mobility. She is incontinent and activity logs show that she has unscheduled bathroom needs at night. Safety concerns are not stand-alone functions in this case. The patient fulfills the criteria for 24-hour care. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with their assessment; it does not appear that her nighttime needs were adequately assessed.

The insurer's denial of coverage for the requested Personal Care Services, 24 hours a day (live-in), 7 days a week is reversed. Medical necessity substantiated.