Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular disease, peripheral neuropathy, radiculopathy, and cognitive impairment.

Treatment: increase in personal care services to 12 hours a day, 5 days a week and 8 hours a day, 2 days a week, a total of 76 hours a week 

The insurer denied coverage for increase in personal care services to 12 hours a day, 5 days a week and 8 hours a day, 2 days a week, a total of 76 hours a week. The denial was reversed.

This patient is a female has extensive medical history including cerebrovascular disease, peripheral neuropathy, radiculopathy, shunt for hydrocephalus, heart failure, arthritis, incontinence and cognitive impairment. The neurologist's letter provided some information about the patient's neurologic conditions and symptoms; including effect on physical and cognitive function. The UAS indicates patient has pain in back and lower extremities which is likely related to lumbosacral spondylolisthesis, radiculopathy, and arthritis. Discharge summary from hospitalization early 2019 for heart failure indicates patient had significant fluid overload which improved with diuresis. The presence of heart failure in frail elderly patients is associated with increased morbidity and mortality.

As a consequence of multiple co-morbidities, the patient has had significant functional decline. The UAS indicates the patient is dependent on caregiver assistance for all IADLs and ADLs; most at a high level of assistance (total dependence, maximal or extensive assistance). The patient lives with her daughter (who works full-time). The insurer approved 41 hours PCS per week. The patient advocate acting on behalf of the patient is appealing the denial of request for 76 hours PCS per week.

In order to determine PCS hours, it is necessary to identify the patient's ADL needs throughout the day. Some ADLs can be scheduled with an approximate timeframe for completion; such as bathing, personal hygiene, and dressing. As per UAS the patient needs extensive to maximal assistance for these activities but they can be done within a limited period of time each day. The patient needs limited assistance for eating; and though meals can be scheduled, someone must be present to assist patient with all her meals, which includes time in the morning, afternoon and evening. In addition, the patient needs maximal assistance for meal preparation. Leaving prepared meals for the patient is not an acceptable plan, as daughter reports that due to safety risks in the kitchen, patient was told to stay out of the kitchen. Some ADLs cannot be scheduled as they occur at various times throughout the day, i.e. walking, transfers, toileting/incontinence care. The patient depends on caregiver assistance for all these ADLs. 

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. Daughter is requesting PCS 76 hours per week; so it is reasonable to conclude that the daughter is not able to provide care to her mother during those hours. Caregiving can be a stressful responsibility. The daughter provides substantial time for the care of her mother. The hours the daughter needs for work and other responsibilities need to be covered by another caregiver to assist her mother. No other informal caregivers are identified by the daughter or UAS. Therefore, it is medically necessary for PCS to provide assistance with ADLs and IADLs during hours the daughter is not available. 

Personal care services are medically necessary for 12 hours per day x 5 days per week and 8 hours per day x 2 days per week, total of 76 hours per week. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for increase in personal care services to 12 hours a day, 5 days a week and 8 hours a day, 2 days a week, a total of 76 hours a week is substantiated.  The insurer's denial is reversed.