Appeal type: Medical necessity
Decision: Overturned

Diagnosis: fracture of the right femur

Treatment: personal care services of 24 hours a day, 7 days a week (live-in)

The insurer is denied coverage for personal care services of 24 hours a day, 7 days a week (live-in)

The denial is overturned. 

This female patient has a history of coronary heart disease, hypertension, atherosclerotic heart disease, diverticulosis of the intestine, gastroesophageal reflux disease, osteoporosis, osteoarthritis, hearing loss and muscle weakness. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY). The patient was hospitalized due to a fall and sustained right periprosthetic fracture of the right femur. The patient underwent an open reduction and internal fixation surgery. She receives nursing, physical therapy and occupational therapy services. Prior to these events, the patient lived alone in a 4 bedroom private home with wheelchair access and a ramp.  The patient is totally dependent for ordinary housework, managing stairs and shopping. The patient needs maximum assistance with meal preparation, transportation, bathing, toilet transfer and locomotion. The patient uses a wheelchair and scooter for locomotion. She needs extensive assistance with managing finances, managing medications, personal hygiene, dressing her upper body, dressing her lower body, walking and toilet use. The patient is frequently bladder incontinent and occasionally bowel incontinent. She uses incontinent supplies. The patient needs limited assistance with phone use, bed mobility and eating. The patient has mild, intermittent pain which is adequately controlled by a therapeutic regimen. An increase to personal care services of 24 hours a day, 7 days a week (live-in) is being requested.

The patient has cognitive impairment. She is totally dependent for ordinary housework, managing stairs and shopping. The patient needs maximum assistance with meal preparation, transportation, bathing, toilet transfer and locomotion. The patient uses a wheelchair and scooter for locomotion. She needs extensive assistance with managing finances, managing medications, personal hygiene, dressing her upper body, dressing her lower body, walking and toilet use. The patient is frequently bladder incontinent and occasionally bowel incontinent. She uses incontinent supplies. The patient needs limited assistance with phone use, bed mobility and eating. The patient has mild, intermittent pain which is adequately controlled. The patient's niece and nephew provide financial assistance and support, but they are unable to provide continuous and daily care due to their work schedule and residing in another state. She still needs assistance with multiple functions, especially transfers.  The patient is an elderly woman status post several falls leading to fractures. She has impairments in instrumental activities of daily living (IADL) and activities of daily living (ADL) as noted above. She needs extensive-maximal assist except for limited assist with bed mobility. She is incontinent. She has no caregivers. She needs help with tasks 24 hours/day, but an aide could expect 5 hours uninterrupted sleep. The patient fits the situation addressed in the WGIUPD GENERAL INFORMATION SYSTEM 



The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the personal care services of 24 hours a day, 7 days a week (live-in)  is overturned.  The medical necessity is substantiated.