Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cerebrovascular Accident
Treatment: Home care / personal care HHC (home health care)- level 2 personal care services, per 15 minutes increase to 24 hours per day (live in)
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in).
The denial is modified.

According to the documentation submitted, this is the case of a patient with a history of coronary artery disease (CAD), status-post (s/p) Transcatheter Aortic Valve Replacement (TAVR), pacemaker insertion and cerebrovascular accident (CVA). According to the Uniform NYS Comprehensive Health Assessment (UAS), the patient lives alone with the family nearby to assist. The patient is totally dependent for meal preparation, shopping and housekeeping. The patient requires assistance for bathing, dressing and locomotion. The patient walks without an assistive device. The patient and their doctor have requested 24 hours split shift of personal assistance service (PAS) per week prior to the denial. The insurer approved a reduction from the request to 65 hours per week leading to the external review.
 
The patient is appealing. The patient needs supervision with activities of daily living such as toileting, dressing, and bathing, as well as help with shopping, cleaning and meal preparation The patient, family and physician believe the patient needs 24-hour split shift PAS (personal assistance services) to prevent further deterioration and maintain this level of care for safety reasons.
 
The NYS Comprehensive Assessment form was reviewed. The patient's cognitive skills are described as basically intact except for occasional forgetfulness and some confusion. The patient is assessed as requiring significant assistance for their Instrumental Activities of Daily Living (IADL) and ADL (Activities of Daily Living) tasks including meal preparation, ordinary housework and shopping, dressing, toileting and bathing. The patient is able to walk with an assistive device but needs help with rising from a chair and weight bearing.  The patient's family is reported to be supportive, attentive and available but does not live with the patient.  The patient's physician believes the patient has had increased weakness of the extremities since having a CVA (cerebrovascular accident) and is at risk for falling. The patient was hospitalized for a fall and is on Eliquis for cardiac disease. This also increases the risk of serious injury during a fall. The patient is incontinent of bladder which also increases the risk of falls. The hours approved assist the patient with the tasks listed above and for getting ready for intermittent doctor's appointments. 

PAS (personal assistance services) hours are approved primarily to provide hands-on assistance for completion of IADL/ADL (Instrumental Activities of Daily Living (IADL) and ADL (Activities of Daily Living) tasks when no one else is available to provide assistance. 
 
Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained with an increase to 84 PAS (personal assistance services) hours/week.  The patient's family is supportive and available for help.  However, the patient lives alone.  The patient also has the means for emergency assistance but needs help with phoning. The patient also has the option of restructuring and flexibly using the 84 PAS (personal assistance services) hours weekly to better maintain and meet their functional needs.  
 
Based on the above, the insurer's denial must be modified. The health care plan did act reasonably in part and with sound medical judgment and in the best interest of the patient. 

The medical necessity for home care / personal care HHC (home health care)- level 2 personal care services, per 15 minutes increase to 24 hours per day (live in) is not substantiated. However, 84 hours per week is substantiated.