Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, gastroesophageal reflux disease (GERD), carotid artery stenosis, dysthymia

Treatment personal care services (PCS), level 2 for 9 hours per day, 7 days per week, for a total of 63 hours per week

The insurer denied coverage for personal care services, level 2 for 9 hours per day, 7 days per week, for a total of 63 hours per week

The denial is overturned

This has several medical conditions contributing to functional impairment and needs assistance with all daily activities. The patient receives personal care services (PCS) 48 hours per week, 5 days x 6 hours: 2 days x 9 hours. Uniform Assessment System (UAS) indicates patient lives alone. However, Social Supports it is reported that the informal caregiver (daughter) lives with the patient and provides assistance with activities of daily living (ADL) and instrumental activities of daily living (IADLs); with a comment stating that the patient's daughter assists with care after personal care aide (PCA) hours. 
The most recent uniform assessment scale (UAS) provided for review was done. Functional status report indicates patient needs maximal assistance for most IADLs, except managing finances, medications, phone use (limited assistance). The patient needs extensive assistance for most ADLs, except bed mobility, eating (limited assistance).

The UAS reported occasional urinary incontinence. The patient has difficulty walking, and when she is alone, her mobility is probably worse, as she has no caregiver support. If the patient has the urge to urinate and is unable to reach the toilet in time, this results in functional incontinence. This can also increase risk of falls, as attention to safety precautions may not occur when she is in a rush to reach the toilet. This increases risk for falls in the bathroom when she is alone. Falls in the bathroom for older people are associated with increased risk of injury. 

MLTC (Managed Long-Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. When the patient needs assistance with toileting, incontinence care, transfer, walking, food/fluids, this is not stand-alone safety supervision. This is assistance the patient needs for proper and safe completion of daily activities. These care needs must be considered in the determination of the patient's personal care service hours.

Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have a caregiver present at least during daytime to early evening hours when the patient is most active. The patient needs assistance with IADLs and ADLs that occur at various scheduled and unscheduled times throughout the day. This includes routine household tasks, and preparation/service and assistance with eating for all 3 meals; routine morning and evening ADLs (bathing, dressing, personal hygiene); and unscheduled/recurring activities, including toileting related tasks/incontinence care; mobility around the home (transfers, walking). Without adequate assistance, the patient is at risk for adverse health and safety events, e.g., falls/injury; skin damage due to inadequate toileting and incontinence care; nutritional decline, dehydration.

Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unable to provide care on a regular basis, then personal care services are indicated to provide necessary assistance for daily activities, including ADLs that occur at various and unscheduled times throughout the day. 

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 personal care services, level 2 for 9 hours per day, 7 days per week, for a total of 63 hours per week is overturned. Medical Necessity is substantiated.