Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure

Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services of 24 hours per day (live in)

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

The denial is overturned

This 87-year-old female has diagnoses of chronic obstructive pulmonary disease (COPD) and heart failure. The patient lives alone. She needs oxygen (O2) and uses bi-level positive airway pressure (BiPAP) at night. She was recently discharged from rehab after a fall which resulted in a fractured foot. The patient requested live-in services. The request was denied as not medically necessary; with continuation of current services, 91 hours per week.

It was noted that live-in aides are paid for 13 hours per day, 91 hours per week (the other 11 hours per day are 3 hours for meals and 8 hours of sleep for the aide). Therefore the patient did not request an increase in hours; she requested a change in status to use the 91 hours as live-in. The Uniform Assessment System (UAS) noted patient has difficulty moving to standing position and has unsteady gait. She has a foreseeable but preventable risk of falling and injuring herself again. The patient has advanced COPD which is noted to be a significant risk factor for falls. The patient had two hospitalizations in the past year and a half for falls, plus several falls that did not require hospitalization. The patient is also incontinent at times, and has history of (h/o) urinary tract infection (UTI); inadequate hygiene could lead to another UTI.

The patient has no informal caregivers. The attorney reported that in the past, the patient's family was available to the patient when the aide left at night, but this is no longer the case. The patient has no assistance after the aide's 13 hour shift.

Live-in care for the patient is medically necessary, as indicated in the physician's letter of medical necessity. Request is made to designate the authorized 91 hours per week as live-in.

It was noted in the UAS that there was one informal caregiver who provided some assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). The attorney indicated the family was previously able to provide some assistance after the aide's 13 hour shift ended each day; but that assistance is no longer available. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide assistance on a consistent basis, then personal care services are indicated to provide necessary care when needed throughout the day and night. In this case, the patient would benefit from having additional assistance through the night to help decrease occurrence of falls/injury during out-of-bed mobility (transfers, walking, toileting); assist with toileting and incontinence care to improve patient comfort and prevent skin damage; assist patient when she needs help adjusting her respiratory apparatus; ensure patient has access to her medication, and assist with repositioning, when needed to help her respiratory status.

Home Care/Personal Care Home Health Care - Level 2 Personal Care Services, per 15 minutes 24 hours per day (live-in) is medically necessary. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the requested Home Care / Personal Care Home Health Care - Level 2 Personal Care Services of 24 hours per day (live in) is reversed. Medical necessity is substantiated.