Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional impairment; Dementia. 

Treatment: Home Care / Personal Care Home Health Care (HHC) - Level 2 Personal Care Services of 24 hours per day (split shift). 

The insurer denied coverage for Home Care / Personal Care HHC - Level 2 Personal Care Services of 24 hours per day (split shift). 

The denial is overturned. 

This is a female patient diagnosed with gastroesophageal reflux disease (GERD), hyperlipidemia, hypertension, hypothyroidism, dementia, knee pain, lumbar spondylosis, osteoporosis, pneumonia, scoliosis, mixed incontinence, dizziness, and giddiness. The patient lives alone on the fifth floor of an apartment building. Her daughter oversees her care. Her son-in-law is also named as a caretaker. The patient is wheelchair bound. The documentation indicates the patient needs total assistance with her activities of daily living (ADL) and instrumental activities of daily living (IADLs). She is totally dependent for meal preparation, ordinary housework, managing finances, managing medications, phone use, stairs, shopping, transportation, bathing, dressing her lower body, locomotion, and toilet use. The patient uses pull ups for incontinence. The patient needs maximum assistance with personal hygiene, dressing her upper body and bed mobility. She needs extensive assistance with eating. An increase personal care services of 24 hours per day (split shift) was requested.

The plan approved 24 hours per day live in. The request is for 24 hours per day/ 7 days per week (split shift). 

A letter from the patient's doctor indicates the patient is incontinent of bladder/bowel, and unable to get up from bed. The patient is wheelchair bound. The patient is unable to turn/position. 

The New York State Department of Health's Uniform Assessment System (UAS-NY) notes the patient has personal care assistance (PCA) of 7 days per week, 24 hours per day. She has total dependence for meals/housework, medications/finances, maximal assistance for bathing, personal hygiene, and toilet use. The patient has bladder continence- daily incontinent using pullups.

A previous Uniform Assessment System (UAS) report notes the patient was ambulating with cane, slowly indoor/outdoor, and she needed assistance using shower and using pullups. The patient had bowel continence- some control of bladder was present.

Records indicate that the deterioration noted in the UAS followed a hospital admission after which despite a period of rehabilitation the patient's condition never returned to her prior baseline.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient is now wheelchair dependent with need for maximal assistance for bathing, personal hygiene and toilet use. The log documents multiple episodes of need for changing and cleaning during the night that would not allow for 5 continuous hours of sleep for the aide. Without appropriate management of toileting, the patient is at risk for pressure ulcers. 

The insurer's denial of coverage for Home Care / Personal Care Home Health Care (HHC) - Level 2 Personal Care Services of 24 hours per day (split shift) is overturned. Medical necessity is substantiated.