Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diagnoses include cerebrovascular accident (CVA) and vascular dementia

Treatment: requested 24 hours x 7 days of (continuous services) per week

The insurer denied coverage for requested 24 hours x 7 days of (continuous services) per week. The denial was reversed.

This patient is a female who was residing in a nursing home since transfer from the hospital mid-2019. The patient had a CVA which improved with reportedly no focal deficits. She was transferred to a nursing home for short term rehabilitation. She was discharged from PT/OT after a few weeks. She demonstrated improvement with mobility and ADLs. A second course of PT/OT was needed after a functional decline was noted. Other medical problems include dementia, atrial fibrillation, hypertension, urinary retention (urology note not available, but it appears Foley was removed), urinary incontinence, osteoarthritis, diabetes mellitus (DM).

The records include a description of the patient at different times over the past few months, and there are some similarities and some differences. It is necessary to identify the patient's current needs in order to determine how much care she will need at home if she is discharged in the near future. The patient demonstrated improvement with her initial course of treatment with PT and OT, but her skills declined after discharge from PT/OT and she was referred to rehabilitation again. She began a second course of treatment; it is not clear whether she has completed it yet. Current progress notes indicate she is being treated for pneumonia, and so PT and OT may be on hold. The patient's mental status is also a concern, as she has a history of vascular dementia, which may have worsened after the recent stroke. Some nursing home notes indicate periods of confusion and agitation. The recent psychiatry consult described various aspects of cognitive impairment including impaired judgment, memory and insight. Her mood was anxious and she has had periods of agitation. A recent nursing note indicated one night, the patient was agitated and she was brought to the nursing station for monitoring. 

There is most likely a connection between the patient's cognitive impairment and her declining ADL status. The patient was able to demonstrate improvement in ADLs from her initial course of rehabilitation therapy at the nursing home, but was not able to maintain her ambulation or other ADL skills after discharge from skilled PT and OT services. This is not unusual for elderly people, especially with cognitive impairment. When the patient was in a structured setting for a limited time each day, she was able to learn and improve her skills. But when that structured environment ended, her ability to retain and carry over the lessons from rehabilitation may be limited due to her cognitive deficits.

There does not appear to be a compelling reason to deny the patient the opportunity to return home. She lives with family who can direct her care even if they are not physically present in the home all day. This is consistent with NYS regulations for personal care services. Due to dementia and functional impairments that affect her mobility (transfers, walking and toileting), it is medically necessary to have a caregiver present throughout the day and night when the patient returns home. She will be at high risk for falls if she attempts to walk around the house at night when the family is asleep.

Personal care assistant services 24 hours per day, 7 days per week, continuous services are approved. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

Based on the above, the medical necessity for the requested 24 hours x 7 days of (continuous services) per week is substantiated.  The insurer's denial is reversed.