Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional decline. 
Treatment: home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day live in. 
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day live in. 
The denial is overturned. 

This elderly female has experienced functional decline associated with several medical conditions and needs help with all daily activities. The patient lives alone and has no informal helpers. The patient's power of attorney (POA)/friend/former neighbor was identified as an informal helper. The patient was receiving personal care services/consumer directed personal assistance services (PCS/CDPAS) 56 hours per week. The patient (via designee) requested increase of services to 24 hours per day live-in, which was denied; but the insurer increased PCS/CDPAS to 63 hours per week. 
 
The functional status report for instrumental activities of daily living (IADLs) indicates patient was totally dependent for meal preparation, ordinary housework, shopping, stairs, transportation; she needed extensive assistance for managing medications, equipment management; limited assistance for managing finances, phone use.  For activities of daily living (ADLs), it was noted that walking and transfer toilet did not occur during entire period. The patient was totally dependent for bathing, dressing lower body, locomotion, toilet use; she needed extensive assistance for personal hygiene, dressing upper body; limited assistance for bed mobility; setup help for eating. 

Comparison with prior Uniform Assessment for New York (UAS-NY) indicates decline for most ADLs. 

The patient has chronic pain associated with several medical conditions. The patient has osteoarthritis (OA). The records also include diagnosis of right artificial hip, nursing comments indicate the patient is non-ambulatory since the recent hip fracture. The patient's out of bed mobility is in a wheelchair, wheeled by others. 

The patient has cardiovascular disease; diagnoses include coronary heart disease, arrhythmia, and peripheral vascular disease. 

Toilet transfer did not occur and the patient was totally dependent for toilet use (which includes incontinence care). Patient has frequent bladder and bowel incontinence. The patient is currently receiving PCS/CDPAS 63 hours per week, (9 hours per day if hours are equally allocated over 7 days); and so, the patient has no help for 15 hours per day. 

Considering the patient's medical history and functional status as identified in the available records, it is medically necessary for the patient to have assistance with all daily activities, which occur at various times of the morning, afternoon, evening, and night, i.e., 24 hour care. 

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 24 hours per day live in services is substantiated.