Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psychosis
Treatment: Custodial Care (Long Term Care)
The health plan denied Custodial Care (Long Term Care) as not medically necessary.
The health plan's determination is overturned.

This is a male with a medical history of hypertensive heart disease, osteoarthritis, stasis dermatitis, psoriasis, and a history of substance abuse. He has been in long term care for approximately 6 months. Adult Protective Services (APS) believes that discharge would be unsafe at this time and requested (on behalf of the patient) an authorization for custodial care (long term care).

In the denial letter for extension of long term care services, the insurance company states that long term (custodial) care was denied because the patient does not have severe impairment of activities of daily living (ADLs). There are no serious mental illnesses or cognitive issues listed in his chart. Therefore, his level of impairment was deemed not sufficient to warrant close contact and constant supervision.

Support for this appeal is provided by the APS administrator and the patient's social worker. These notes state that the patient "cannot be discharged to the community" and that he is "at risk for self-neglect." The documentation states that the patient fell down the stairs but did not seek medical care for injuries related to the fall, and that the client "did not demonstrate capacity to seek help for himself." He is also noted to be unkempt and not caring for his personal needs, with an extended history of not caring for himself. He does not have a home to return to and would have a difficult time managing his needs in the community. The patient is not a candidate to go to assisted living because he is not yet 65. They are requesting a psychiatric evaluation prior to discharge planning, and that he remain in long term care until a safe discharge plan can be implemented.

This evaluation was requested due to 2 incidents of aggression over a 3 day period which prompted a review of his conditions and medications. At that time, he was found to be delusional and paranoid, and alert and oriented to person and place only. Speech was rambling. The diagnosis was unspecified psychosis (F29). There was no follow up evaluation for chronic psychiatric conditions.

At issue is the medical necessity of Custodial Care (Long Term Care).

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Custodial Care (Long Term Care) is medically necessary for this patient. The patient does appear to function independently, and at first look, discharge from long term care may appear appropriate. However, supplemental information provided by APS does corroborate a history of behaviors and lack of ability of the patient to care for himself. Additionally, there was evidence of psychosis on admission to the hospital six months ago without subsequent follow up; it would stand to reason that this symptom occurred concurrently with some long term neuropsychiatric deficits. It is reasonable for a clinician to infer that there are substantial deficits in the patient's ability to care for himself based on the historical patterns of behavior in the patient, even in the absence of a demonstrated deficit on a standardized assessment tool. Therefore, it is reasonable to agree with the APS administrator's interpretation of 10 NYCRR (New York Codes, Rules, and Regulations) Part 405.9 (f) (1), that it is the facility's responsibility to ensure that the patient can be safely returned to the community with all necessary services to ensure that safety. In the absence of these resources, it is highly likely that the patient will be readmitted to the hospital in a short period of time and will be at high risk to sustain negative health consequences due to his inability to care for himself in the interim.

Therefore, the requested health service/treatment of Custodial Care (Long Term Care) is medically necessary.