Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Progressive Cognitive Impairment, Persistent Depressive Disorder
Treatment: Daily Social Day Care (SDC) Services: Total of 3 Days per Week
The insurer denied Daily Social Day Care (SDC) Services: Total of 3 Days per Week.
The health plan's determination is overturned.

The patient is a female with a diagnosis of progressive cognitive impairment (neurocognitive disorder) with persistent symptoms of depression best characterized as persistent depressive disorder. The patient is forgetful with limited functioning related to her mental health issues. The patient does cooperate with self-care and receives Home Attendant Services to assist her with bathing, feeding, dressing, ambulation and toileting. She also receives assistance with general housework including laundry, shopping and meals. She needs some assistance with medications and with the use of transportation. She participates in groups, activities, and other therapeutic interventions at the Day Program including peer support.

The Day Care services occur three days per week and serve to provide socialization and intellectual stimulation. The Day Care services also provide therapeutic intervention for the patient's loneliness, social isolation, and symptoms of depression which include depression, anhedonia and loss of interest together with concentration difficulties in the context of the cognitive impairment.

The patient's health plan has denied coverage for the Day Care services indicating that the services are not medically necessary and that the Personal Care Assistance is sufficient to address the patient's needs. Moreover, the denial indicates that there is overlap with services provided through the Day Care program and Personal Care Attendant. The denial references New York State Department of Health Uniform Assessment System guidelines (UAS_NY).

The patient's adult children, social worker, and physician are requesting coverage for the Day Care Services at a frequency of three days per week together with the personal assistance provided through the Home Attendant Services. The appeal indicates that there is no overlap of these services with Day Care.

The case summary and correspondence from the patient's physician, clinician, adult children, and correspondence from the health plan were reviewed. Also reviewed was information on the extent of the functional decline and needs pertaining to the comorbid conditions of the patient. 

The health plan, in its determination of medical necessity, has not acted reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of Daily Social Day Care (SDC) Services: Total of 3 Days per Week is medically necessary for the patient.  The services being provided are clinically appropriate to address ongoing symptoms of depressive disorder with persistent symptoms of depression and cognitive impairment (neurocognitive disorder) in a patient with multiple mental health issues and functional impairments. The continued use of a Day Program with behavioral health programming and the Day Care services provides for maintenance treatment for the patient's mental health needs and facilitates better functioning and cognition.

The patients functional decline in the context of the comorbid conditions could not be effectively addressed with only Home Attendant Services. The requested benefit of the Day Care Services is reasonable, in the patient's best interest, and reflects sound medical judgement. Thus, the proposed treatment and services with Social Day Care Services at a frequency of three days per week, is consistent with New York State instruction for medical necessity reviews and is consistent with the prevailing standards of care and with the scientific literature referenced below.