Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colon cancer, pulmonary embolism (PE), osteoarthritis, abdominal hernia, and heart failure.
Treatment: Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week.
The insurer denied coverage for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week.
The denial is overturned

This elderly patient has an extensive medical history and has experienced significant functional decline due to various medical conditions. The patient needs assistance with all daily activities. As per the Uniform Assessment (UAS), the patient lives alone. The patient receives some informal help from the daughter. The patient mostly depends on personal care services for assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). The UAS and care plan indicate services are provided as Consumer Directed Personal Assistance Services (CDPAS). The patient receives CDPAS 56 hours per week. The patient (via designee) requested increase of CDPAS to 84 hours per week, which was denied. 

The most recent UAS was reviewed. The functional status report for IADLs indicates the patient was totally dependent for meal preparation, ordinary housework, shopping, stairs; the patient needed maximal assistance for transportation; extensive assistance for managing finances and medications, phone use. For ADLs, it was noted that walking did not occur during the entire period. The patient was totally dependent for locomotion (in wheelchair; wheeled by others); the patient needed maximal assistance for bathing, dressing lower body, transfer toilet, toilet use; extensive assistance for personal hygiene, dressing upper body, bed mobility; supervision for eating. Comparison of the previous UAS indicates decline in function for ADLs.

The patient needs assistance for daily activities at various routine and unplanned times throughout the day, at least from morning to evening, and some ADL care appears to be needed at night. CDPAS hours are flexible, but for a person who needs help with all ADLs and IADLs that require extended time and high level of physical effort (such as weight-bearing), it cannot be expected that 8 service hours per day is sufficient to cover all activities over the course of the entire day. Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime needs for assistance. The patient needs help at various times of the day to help prevent skin damage (due to incontinence, pressure), infection (such as urinary tract infection), help relieve pain; ensure adequate food and fluid intake daily. These care needs must be considered in the determination of the patient's personal care/CDPAS hours. 

As per the UAS, informal help was reported as 15 hours over the previous 3 days (one informal helper). It is not known if this amount of informal help (5 hours per day) can be expected on a regular basis. Considering the request for personal care services is for 84 hours per week, it is reasonable to conclude there are no informal helpers who can provide assistance for that amount of time through the week. As per New York State regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide care on a regular basis, then personal care services (in this case, CDPAS) are indicated to provide assistance for ADLs and IADLs when needed, including tasks that occur at unscheduled and/or recurring times of the day. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 84 hours per week is substantiated.