Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, angina, gastroesophageal reflux disease (GERD), and Non-Hodgkin lymphoma

Treatment: Personal Care Worker (PCW) 7 days per week, 10 hours per day for a total of 70 hours per week

The insurer denied coverage for PCW 7 days per week, 10 hours per day for a total of 70 hours per week

The denial is overturned.

This female has experienced functional decline associated with several medical conditions. She needs help with most daily activities. She has been receiving assistance through PCW services. Social support section in the recent Uniform Assessment System (UAS) report indicates the husband is the only informal helper. The patient was receiving PCW services 31 hours per week. The patient (via designee) requested increase of PCW services to 70 hours per week, which was denied; but the insurer increased PCW services to 35 hours per week. External appeal was requested.

The patient's ability to function is limited by multiple problems including various effects from Parkinson's Disease (PD), substantial fatigue (PD, lymphoma, anemia, depression), chronic pain, and other reported symptoms such as dizziness and dyspnea. The combined effects of these symptoms and limitation of movement are physically stressful and can further increase symptoms of depression and anxiety. The UAS reported patient needs assistance with all activities of daily living (ADLs) and most instrumental activities of daily living (IADLs). It is necessary to have a caregiver present to provide assistance to help relieve some of the burden of performing daily activities.

Considering the information provided for review, it is medically necessary for the patient's health and safety to have caregiver support for all routine ADLs and IADLs, and ADLs that occur at unscheduled and recurring times during the day, including toileting, mobility, meals. Managed Long-Term Care (MLTC) 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. All the patient's care needs throughout the day must be considered in the determination of personal care service hours. Additional PCW hours would not be used for stand-alone safety supervision; assistance is needed for proper and safe completion of ADLs and IADLs.

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at unscheduled and recurring times throughout the day (e.g., toileting, incontinence care, mobility). Considering the patient (via designee) is requesting PCW 10 hours per day, 7 days per week, it is reasonable to conclude that there are no informal caregivers available to provide assistance for that period of time each day on a regular basis.

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 Worker (PCW) 7 days per week, 10 hours per day for a total of 70 hours per week is reversed. Medical Necessity is substantiated.