Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, hypertension, hyperlipidemia
Treatment: home care / personal care HHC (home health care) - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift)

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift).
The denial is overturned.

According to the documentation submitted, this is the case of an elderly patient with a history of Leiden mutation, coronary artery disease, hypertension, hyperlipidemia, ischemic cardiomyopathy, implantable cardioverter defibrillator, chronic systolic congestive heart failure, syncope, advanced dementia, paranoia, prurigo nodularis with sores on her body, bowel obstruction, blind, uses bilateral hearing aids, and has a history of falls. Per New York State Department of Health's Uniform Assessment System (UAS-NY), the patient resides alone, and she receives 84 hours per week of consumer directed personal assistance services. She is totally dependent for meal preparation, ordinary housework, managing finances, managing stairs, shopping, transportation, toilet use and locomotion. The patient uses a wheelchair or scooter for locomotion indoors. She needs extensive assistance with managing medications, bathing, bed mobility and toilet transfer. She is frequently bladder incontinent but has complete bowel control. The patient needs limited assistance with personal hygiene and dressing her upper and lower body. She is independent with phone use. The patient reported at times having right sided rib pain from a previous fracture after a fall. The patient takes Tylenol to relieve her pain. It was noted the patient had a stomachache and vomited twice one day. Emergency medical services responded, but the patient declined to be transported. 

The UAS (Uniform Assessment System) identifies two informal caregivers; though it is not clear whether they live with the patient. It appears there is some type of informal caregiver assistance during non-PCS (personal care services) hours, but the extent of the time and services is not clearly described. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance for daily activities, including activities of daily living (ADLs) that occur at various unscheduled and recurring times throughout the day and night. The daughter is requesting PCS 24 hours per day, split shift. Therefore, it is reasonable to conclude that there are no informal caregivers who can provide care for an extended period of time during the day or night on consistent basis (current informal caregiver(s) may no longer be able to provide care). The available information supports the need for PCS continuous services.

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 Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is overturned. Medical Necessity is substantiated.