Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, osteoarthritis, hypertension. 
Treatment: increase in coverage for Personal Care Assistance, for a total of 12 hours per day 7 days per week, Monday through Sunday, total of 84 hours per week. 
The insurer denied coverage for increase in coverage for Personal Care Assistance, for a total of 12 hours per day 7 days per week, Monday through Sunday, total of 84 hours per week. 
The denial is overturned. 
 
This case involves an elderly female with a subject for review for the Denial of coverage for Personal Care Assistance, for a total of 12 hours per day 7 days per week, (Monday
through Sunday), total of 84 hours per week. 

In this case, the patient lives alone in a one-bedroom apartment in a safe building with elevator access. She has a history of Alzheimer's disease, osteoarthritis (OA), hypertension (HTN), Depression, Anxiety, Dizziness, Poor balance, and difficulty in walking. Per the assessment, the patient is moderately impaired, alert and oriented to person, disoriented to time and place. She is not able to activate a personal emergency response system (PERS) or call 911 in case of emergency. She is sometimes understood and understands and responds adequately to simple, direct communication only. She has limited vision due to glaucoma. She is totally dependent with meal preparation, ordinary housework, shopping, and managing finances. Maximal assistance with managing medications, phone use, transportation, equipment management, bathing, and dressing the lower body. Extensive assistance is needed with personal hygiene, dressing the upper body, walking, locomotion, transfer to toilet, toilet use, Limited assistance with bed mobility, and eating. 

NY (New York) State regulations do not require personal care assistance services for safety supervision alone, such as may be clinically necessary for someone with cognitive dysfunction. Personal care assistance hours for companion care or for safety supervision, without the need for activity of daily living tasks, is not required to be covered under the benefit plan. 

Safety supervision is included and covered as part of the total authorized personal care service hours when done during activities of daily living. 

The information stated that the member's son and daughter are able to assist member after service hours with bathing, dressing, meal preparation, shopping, escort to MD (doctor of medicine) office and walking. However, they do not live with her and would not be readily available to assist with toilet use and toilet transfer or any other activities of daily living such as walking. The  patient fell and fractured her wrist and her limitations are increased. She also has limited vision due to glaucoma. The approved hours are not sufficient to meet her needs such as meal preparation, ordinary housework, managing her finances, shopping, managing medications, phone use, transportation, equipment management, bathing,  dressing the lower body, personal hygiene, dressing the upper body, walking, locomotion, transfer to toilet and toilet use. The son reports urinary incontinence and one person assist is need for toileting. As such the denial for the total of 12 hours per day 7 days per week, (Monday through Sunday), total of 84 hours per week is reversed and  84 hours per week are considered medically necessary. 

Based on the above, the insurer's denial should 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 Personal Care Assistance, for a total of 12 hours per day 7 days per week, (Monday through Sunday), total of 84 hours per week is substantiated.