Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, osteoporosis
 
Treatment: Increase to Personal Care Worker Services, 7 days per week at 12 hours per day.

The insurer denied the Increase to Personal Care Worker Services, 7 days per week at 12 hours per day. The denial was reversed.   

This is an elderly female patient with a history of congestive heart failure, paroxysmal atrial fibrillation, hypertension, hyperlipidemia, lumbar spinal stenosis, osteoporosis, arthritis, vertigo, and unsteady gait. It was reported that she requires assistance with most of her activities of daily living (ADLs) due to vertigo and her unsteady gait. She requires prompting and assistance with her medication. A request was made for an increase in Personal Care Services from 5 hours a day 7 days a week to 12 hours a day 7 days a week due to her declining functional status.

Osteoarthritis/degenerative disc disease/spinal stenosis/osteoporosis: The physician's letter indicates patient has difficulty walking due to arthritis.  Recent lumbosacral spine x-ray shows partial compression fracture (T11, T12) and degenerative disc disease (lumbosacral spine).  The physician also reports h/o spinal stenosis (no details provided).  The UAS reports that patient has unsteady, slow gait (timed 4 meter walk: 30 sec); daily pain; difficulty moving to standing position.  Arthritis is a frequent cause of functional impairment in elderly people as a result of chronic pain and limitation of movement.  The full extent of the patient's arthritis is not noted, but back pain appears to be a prominent feature.  

Functional impairment in elderly people is usually the result of the combined effect and interaction of multiple medical conditions and the effects of multiple drugs.  This patient has various medical problems contributing to gait impairment and unsafe mobility.  She has chronic pain, dizziness and fatigue which cause difficulty with transfers, ambulation and toileting. Her impaired memory and decision making capacity can result in poor safety choices when performing ADLs alone. The patient has multiple medical conditions contributing to functional impairment and the need for assistance with most daily activities.  Therefore, it is medically necessary for the health and safety of the patient for a caregiver to be present throughout the hours of the day when the patient is most active and needs help with ADLs and IADLs, including ADLs that occur at unscheduled times throughout the day (i.e. transfers, walking, toileting). 

Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services. The request for additional PCW hours is for 12 hours per day, 7 days per week; and so it is reasonable to conclude that there are no informal caregivers who can provide consistent and sufficient hours to ensure a total of 12 hours of assistance per day.  Therefore, without adequate provision of care from informal caregivers, then additional PCW hours are medically necessary.

There is still some concern for the patient during the night hours; as it is probable the patient needs to use the toilet during 12 hours at night.  The patient may have other reasons to get out of bed when alone at night, and so she needs assistance for transfers and walking.  It is not known whether family members stay with the patient for any period of time at night.  The maximum number of hours that can be approved from this review is limited to the amount of time requested, i.e. PCW 12 hours per day x 7 days per week.  Re-assessment will determine whether PCW nighttime hours are necessary. 

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

The carrier's denial of coverage for the increase to personal care worker services 7 days per week at 12 hours per day is reversed.  The medical necessity is substantiated.