Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary heart disease, heart failure, osteoporosis, angina, hypertension, hyperlipidemia, blindness in the right eye, malignant neoplasm of the skin, and osteoarthritis
Treatment: Personal care services ,24 hours a day, 7 days a week (live in), totaling 91 hours per week
The insurer denied coverage for personal care services ,24 hours a day, 7 days a week (live in), totaling 91 hours per week
The denial is overturned.

This elderly patient is currently residing in a skilled nursing facility (SNF) where she was admitted for short term rehabilitation. The Uniform Assessment System (UAS) reported patient was in the hospital for 2 weeks, but the records provided for review do not include information about hospitalization (admission diagnosis is not noted). Prior to hospitalization and SNF admission, the patient was living alone and was receiving personal care services (PCS) 56 hours per week to assist with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The SNF physician's letter recommended 24-hour care for the patient when she returns home.

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

The patient has impaired mobility/unsteady gait due to effects of weakness, dyspnea, fatigue, dizziness, poor balance, and possibly arthritis. She has some degree of cognitive impairment and may not always remember her limitations; so, she may try to get up and walk when she is alone. The last physical therapy (PT) note indicated patient was walking 40 feet with walker and moderate assist; and needed moderate/maximal assist for transfers. It does not appear the patient can safely move around her home without help. 

The patient has been residing in the SNF. When she is discharged, there is most likely going to be a transition period in which the patient will need to re-adjust to living at home. In the SNF, the patient has assistance for all ADLs, meals, medications through the day and night. Based on available information, the patient's care needs support 24-hour personal care services when she returns home, as she needs assistance with all IADLs and ADLs, including assistance with tasks that are necessary during day, evening and nighttime hours.  

As per New York State regulations for personal care services, in order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8-hour sleep period each day. A detailed activity log describing current frequency of the patient's ADL and IADL care was not provided for this review. However, based on available information at this time, currently approved PCS 60 hours per week is not sufficient to meet the patient's daily care needs. A live-in aide can help the patient with all daytime tasks, plus her evening and nighttime care needs including dinner, medications, dressing, personal hygiene, mobility, toileting, incontinence care, repositioning in bed. 

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 personal care services 24 hours a day, 7 days a week (live in) services is substantiated.