Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus, essential primary hypertension.

Treatment: consumer directed personal care assistance of 8 hours per day, 5 days per week for a total of 40 hours per week.

The insurer denied coverage for consumer directed personal care assistance of 8 hours per day, 5 days per week for a total of 40 hours per week.

The denial is overturned.

This is the case of a female patient with a past medical history of depression, paranoid schizophrenia, type 2 diabetes mellitus, essential primary hypertension, microcytic anemia, musculoskeletal pain, osteoarthritis, and hyperlipidemia. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her personal care aide were present on the call. The patient's diagnoses of osteoarthritis, depression and schizophrenia have made it difficult for her to perform her activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Her diagnoses of depression and schizophrenia are controlled with medication. 

The patients' needs are: 

1) Maximal assistance for meal preparation, ordinary housework, and shopping;
2) Extensive Assistance for managing medications, managing stairs, transportation, bathing, personal hygiene, and dressing her upper and lower body;
3) Limited assistance for managing finances, phone use, equipment management, toilet transfer, and toilet use;
4) Supervision/Independence for walking, eating and locomotion [uses assistive devices (ADs)]. She is independent with bed mobility.
5) Cognition: There is mild impairment. 
6) Continence: There is occasional urinary and no bowel incontinence. She uses pull-ups.

An increase to consumer directed personal care assistance of 8 hours per day, 5 days per week for a total of 40 hours per week is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 7/6/16 

(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The provision of diapers and durable medical equipment (DME) such as alternate pressure beds is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" (www.ncbi.nlm.nih.gov) changing diapers regularly and positioning are also necessary. 

Current authorization is for 2.7 hours/day for 5 days a week. The plan has denied 8 hours/day 5 days a week. 

There are no informal caregivers. 

The patient has physical and psychiatric impairments leading to ADL needs as noted above. Her needs include help with all meals, IADLs, transfers, toileting, and cleaning up after incontinence (see ADL log). These needs are daily and some are unscheduled. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's assessment of the patient's needs.		

The insurer's denial of coverage for the requested Consumer Directed Personal Care Assistance of 8 hours per day, 5 days per week for a total of 40 hours per week is overturned. Medical necessity is substantiated.