Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia; cerebral infarction

Treatment: Personal care services 

The insurer denied coverage for personal care services. 

The denial is reversed.  

This female with diagnoses: B12 deficiency, arteriosclerotic heart disease (ASHD), cerebral infarction, dementia without behavioral disturbance, dyspepsia, gastroesophageal reflux disease (GERD), status post gastric volvulus/surgical repair, hypertension, hyperlipidemia, urinary incontinence, osteoarthritis, shortness of breath, pleural effusion, Zoster complicated by cellulitis and pain (postherpetic neuralgia treated with gabapentin). The UAS indicates that patient depends on caregiver assistance for all IADLs (extensive or maximal assistance). For ADLs, the patient needs extensive or limited assistance for all activities except bed mobility and eating (independent set up help).

The patient has dementia, treated with memantine and rivastigmine. The extent of the patient's cognitive impairment is not clear. The UAS notes decision making capacity as only minimally impaired but the family directs care; makes medical and financial decisions. The patient is never left unattended to ensure safety. Mini-Mental State Examination (MMSE) was 10/30 (borderline between moderate and severe cognitive impairment). At the neurologist's office the patient was not oriented to time or place. Decline in ability to perform daily activities is an expected consequence of dementia as the disease progresses. It is not clear how much of the patient's functional decline can be attributed to cognitive impairment, but it is likely a contributing factor for most IADLs and possibly some ADLs (decline of IADL skills usually precedes ADL decline).

The UAS notes that the patient has frequent dizziness, shortness of breath with walking, unsteady gait, difficulty standing up without assistance. At the time the UAS was done, the patient needed limited assistance with ambulation and toileting related tasks. Pain was noted as not an issue. However, the notes from the patient's primary care physician (PCP) and Neurologist include additional and updated information not noted in the UAS. The patient was diagnosed with zoster, treated with Valtrex; complicated by cellulitis and significant pain. The PCP noted patient now uses a wheelchair for transport in and out of the home. The neurologist reported patient is sedentary, and she is unsteady when she gets up. She had a few falls (hit her head once but no medical evaluation was done).  

The patient has been receiving PCS 7 hours per day, 5 days per week. It was noted in the UAS that the son assists the patient on weekends when he is home; but the amount of time he is home on weekends was not noted. The neurologist noted that the son reported he has difficulty providing care to his mother on weekends. Without consistent availability of the son (or another informal caregiver) to provide the patient with necessary assistance for daily activities on weekends, then a new care plan is necessary. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. There are no other informal caregivers identified in the available records who can provide care to the patient on weekends. In the absence of informal caregivers who can provide care on weekends, then personal care services are indicated to provide the patient with assistance for ADLs and IADLs on weekdays and weekends, i.e. 7 hours per day, 7 days per week, 49 hours per week.

Personal Care Assistance Services Level II 49 hours per week are medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for Personal Care Services, Level ll, 49 hours per week is reversed. The medical necessity is substantiated.