Appeal type: Medical necessity
Decision: Upheld

Diagnosis: General debility due to stroke
Treatment: Social Day Care (SDC) - Center-Based Day Care 
Services; Per Diem Increase to 2 Day(s) per Week
The insurer denied: Social Day Care (SDC) - Center-Based Day Care Services; Per Diem Increase to 2 Day(s) per Week
The denial is upheld.

The patient is an adult male with a history of general debility due to a history of stroke. The request was for Social Day Care (SDC) Services Assistance through Center-Based Day Care Services to be increased per diem to two days per week based on the Uniform Assessment System (UAS) of last year. The health plan denied the request because the patient already has consumer directed personal assistance services (CDPAS) personal care hours (21 hours per week) to meet personal needs. These hours provided are sufficient to complete all needed functional tasks and social daycare is considered an alternative way to meet personal care needs. The Social Day Care hours requested are because of the patient's chronic medical conditions and to enable him to interact socially because of his depression and loneliness. The Social Day Care hours will enable him to meet his cultural and social needs and the need for him to socialize with people from his country Egypt due to feelings of loneliness and isolation as a Muslim. A review of the records showed that the patient has multiple chronic medical conditions including history of cerebrovascular accident (CVA), falls, hyperlipidemia, osteoarthritis, hypertension, benign prostatic hyperplasia (BPH), dizziness, retinal detachment, and glaucoma. Uniform Assessment System-New York (UAS-NY) evaluation of last year showed that the patient is cognitively intact and independent in making decisions consistently reasonably and safely, independent with managing finances, phone use, bathing, personal hygiene, locomotion, toilet use/transfer, bed-mobility, eating; required limited assistance with upper/lower body dressing, walking; required extensive assistance with shopping, managing medications, stairs, and required maximal assistance for meal preparation, housework, shopping, and transportation. 
The patient lives in a first-floor condominium with his son.

The requested health service is not medically necessary.

The requested Social Day Care (SDC) Services Assistance through Center-Based Day Care Services to be increased per diem to two days per week is not medically necessary because the patient is cognitively intact and independent in making decisions consistently reasonably and safely and independent with managing finances, phone use, bathing, personal hygiene, 
locomotion, toilet use/transfer, bed-mobility, and eating. The patient can use his consumer directed personal assistance services time to socialize. The reason for denial by the health plan as stated in the clinical information above, does align with this patient's disability features as stated in the Uniform Assessment System of last year as stated above. Therefore, the Social Day Care (SDC) Services Assistance through Center-Based Day Care Services to be increased per diem to two days per week requested should not be approved. The 
requested health service is not medically necessary.