Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, chronic obstructive pulmonary disease, hyperlipidemia, hypothyroidism, glaucoma, insomnia.
Treatment: Home care / personal care HHC [home health care] - level 2 personal care services of 24 hours per day (live in).

The insurer denied coverage for home care / personal care HHC - level 2 personal care services of 24 hours per day (live in).  The denial is overturned.

The patient is a male with a past medical history of dementia, chronic obstructive pulmonary disease, hyperlipidemia, hypothyroidism, glaucoma, insomnia, acute ischemic heart disease, muscle weakness, abnormal gait and mobility, as well as a history of falling. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and his son were present for the assessment. It was noted that the patient confuses time or place, and he is unable to recall names. He is also unable to direct his own care, and his children make decisions for him. The patient is more confused status post (s/p) a fall. 

The patient's needs are:  1) Total dependence for meal preparation, ordinary housework, shopping and toilet use, 2) Maximal assistance for managing finances, managing medications, phone use, managing stairs, transportation, bathing, personal hygiene, dressing his upper and lower body, walking, toilet transfer and locomotion (was supervision when assessed), 3) Limited assistance for bed mobility (independent), 4) Cognition: There is severe impairment, 5) Continence: There is frequent urinary and occasional bowel incontinence. He uses pull-ups. 

The patient's primary diagnosis of dementia with confusion and forgetfulness, unsteady gait and difficulty walking affect his ability to manage his activities of daily living (ADLs) and instrumental activities of daily living (IADLs). He also uses durable medical equipment (DME) for his activities.

An increase to home care / personal care HHC - level 2 personal care services of 24 hours per day (live in) is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 

(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The patient has severe dementia and needs assistance with all ADLs as noted above. Nighttime Needs Log demonstrated need for toileting at night; he cannot use bathroom or manage soiled pull-ups on his own. The provision of diapers and DME is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" (www.ncbi.nlm.nih.gov) changing diapers regularly and positioning are also necessary.

The patient has no scheduled informal caregiver. He has deteriorated since evaluation, now needing assistance with bed mobility and more assistance with locomotion. Any supervision or safety concerns are part of providing tasks. The request for increased hours is approved. 

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 the requested Home Care / Personal Care HHC - Level 2 Personal Care Services of 24 hours per day (live in) is overturned. Medical necessity is substantiated.