Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Assistance services, Level 2, 7 hours per day 7 days per week, total 49 hours. 

The insurer denied coverage for Personal Care Assistance services, Level 2, 7 hours per day 7 days per week, total 49 hours. 

The denial is overturned. 

This is a male patient who has significant functional impairment that requires caregiver assistance for all daily activities. The patient lives with his wife who also has health problems and needs assistance with daily activities. The patient is approved for personal care services (PCS) 5 hours per day, 35 hours per week. The patient's wife receives the same amount of services. This is a mutual case; and so together they receive PCS 10 hours per day with shared services for household tasks. The wife requested increase of PCS for her husband to 7 hours per day, which would bring total daily PCS to 12 hours. 

The Uniform Assessment System (UAS) report indicates the patient is totally dependent or needs maximal assistance for all instrumental activities of daily living (IADLs). The patient needs maximal or extensive assistance with most activities of daily living (ADLs); except walking, locomotion and bed mobility (limited assistance). The patient has diagnosis of dementia. He may have physical impairments that limit his ability with ADLs; but considering that he also has severe memory impairment and poor decision making ability with daily tasks, it is likely that his cognitive deficits contribute to his functional impairment and need for ADL assistance. The UAS identifies some additional medical conditions that probably contribute to the patient's functional limitations and/or are exacerbated by his cognitive impairment including benign prostatic hypertrophy, bowel incontinence, unsteady gait, and a history of falls. 

The patient has substantial functional limitations with daily activities as a result of significant cognitive impairment and several other medical conditions affecting his activities of daily living. It is medically necessary for the patient to have caregiver assistance with all daily activities. The patient's care needs are not limited to 10 hours per day (current total number of PCS hours as a mutual case with his wife). Walking, transfers and toileting related tasks can occur throughout the day and night. Even for more time limited tasks, such as eating, dressing, personal hygiene, 10 hours per day may not be sufficient to complete all tasks needed for the day. 

The UAS indicates the patient's wife is the only informal caregiver. She has health problems and functional limitations, and she also requires caregiver assistance for her own daily activities. It is in the best interest of the patient and his wife to limit her responsibility as the patient's caregiver to the type and frequency of care she feels she can provide. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. The wife is requesting an additional 2 hours of personal care services per day for her husband. It is reasonable to conclude that she is unable to provide care during these hours. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance with daily activities when needed throughout the day and night. 

The health plan did not act in the best interest of the patient. 

The carrier's denial of coverage for Personal Care Assistance services, Level 2, 7 hours per day 7 days per week, total 49 hours is overturned. The medical necessity is substantiated.