Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease. 

Treatment: Home Care/Personal Care HHC - Level 2 Personal Care Services. 

The insurer is denied coverage for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 84 Hour(s) per Week, from as not medically necessary. 

The denial is upheld. 

The patient is a male with a medical history of Alzheimer's disease, bilateral knee osteoarthritis, difficulty walking, chronic dizziness, coronary artery disease, benign prostatic hypertrophy.  A Medical Report for Determination of Disability notes cognitive limitations including understanding instructions, making simple decisions, responding appropriately to supervision and dealing with changes in routine setting.  He has limitations in bilateral upper extremity manipulation and in posture.  He walks with limited assistance but needs supervision. 

The insurer has denied coverage for Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 84 Hour(s) per Week  as not medically necessary.  In their Final Adverse Determination letter, they write that the patient lives alone and is oriented to person and place.  He has not had any falls, hospitalizations or emergency department visits in the past 3 months.  There has been no change from the assessment done.  They showed a tasking tool score of 34 and 30, respectively.  He receives 42 hours of personal care services currently; there is no need for increased hours. 

The patient's daughter is appealing on behalf of the patient.  In a letter she notes that the patient's gait is unsteady, he has decreased appetite,  outbursts with behavior, signs of agitation and depression, denial of diaper usage and activities of daily living, has urinary and bowel incontinence, periods of wandering, and is an elopement risk.  In a letter it notes that the patient has recently gotten worse.  He has bowel and bladder incontinence.  An increase in home care hours is recommended. The doctor states that the patient has dementia and advanced arthritis; his care requires significant physical activity and strength.  The patient's daughter is unable to provide adequate care for the patient any longer, due to her own health conditions. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services. 
(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 patient was assessed and functional status was stable.  The physician notes indicate that more hours are needed.  The available documentation indicates that the patient needs increased supervision, but specific activities of daily living (ADL) needs have not substantially changed.  He has dementia and needs constant cuing and supervision. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 84 Hour(s) per Week is upheld.  The medical necessity is not substantiated.