Appeal type: Medical necessity
Decision: Upheld

Diagnosis: heart disease, macular degeneration, heart failure, osteoarthritis, cognitive decline, hyperlipidemia, hypertension

Treatment: Personal care services (PCS)-24 hours a day, 7 days a week (live in) totaling 91 hours a week

The insurer denied coverage for personal care services (PCS)-24 hours a day, 7 days a week (live in) totaling 91 hours a week

The denial is upheld

This is an elderly patient with a history of stroke with left sided deficit, rheumatoid arthritis, left ventricle hypertrophy, irritable bowel syndrome, and frequent urinary tract infections. The patient has hearing loss and poor awareness from her stroke. No medical/clinical documentation was provided. There are no physician visit notes submitted.

The documentation of the Uniform Assessment for New York (UAS-NY) indicates the participant's needs assistance for preparation, housework, managing finances, managing medications, phone use, stairs, shopping, and transportation.

There are several definitions of home care. Home health care is a system of health care and social services provided at home to people with disabilities or people who must stay at home because of their medical conditions. Home care can also be interpreted as a unit that allows health services to be performed simultaneously or in combination with various health professions as a team to achieve and maintain optimal client health status. Home care for patients with postacute stroke, particularly for those with total dependency, is required to ascertain the maintenance of stroke care and risk factors, prevention of complications and major vascular events, and the continuity of rehabilitation. For a good-quality home care performance, health care providers as well as family and caregivers should collaborate in harmony (Paryono et al., 2022).

There has been a substantial shift in focus away from institutionalization in recent decades for two main reasons. First, patient advocates raised patient well-being concerns and the desire to provide care in the least restrictive setting possible, and laws supporting this desire followed [the Americans with Disabilities Act and the subsequent U.S. Supreme Court ruling on Olmstead v. L.C.]. The Olmstead ruling held that people with disabilities have a qualified right to receive state-funded supports and services in the community when the person's care team determines that community supports are appropriate, the person does not object to living in the community, and the provision of services in the community would be a reasonable accommodation when balanced with other similarly situated individuals with disabilities. Second, increased longevity and strained budgets have led policy makers to advocate for increased reliance on receiving care at home, instead of at nursing homes, where at least some of the care is provided by family and friends and thus is not part of either Medicare's or Medicaid's budget. Informal care, or care provided, often without pay, by people who have a preexisting personal relationship with the care recipient, is viewed as an alternative to paid formal care, but research on informal care has focused predominantly on caregiver outcomes. Relying on informal care was historically a default policy option in the absence of systematic funding for formal care (Coe, N. B., et al. 2021).

When friends and family are unavailable or unable to care for homebound loved ones, primary care often deploys Home and Community Based Services, including home health aides. For these homebound older adults, home health aides are essential to help preserve an independent life at home and avoid nursing home care (D'Cruz, L., et al. 2022).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for personal care services (PCS)-24 hours a day, 7 days a week (live in) totaling 91 hours a week is not substantiated.