Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia, Severe Osteoarthritis

Treatment: Personal Care Services 9 hours a day, 7 days a week

The insurer denied coverage for Personal Care Services 9 hours a day, 7 days a week.

The denial is overturned.

This is a female patient with diagnoses: Alzheimer's dementia, right knee large medial meniscus tear, severe osteoarthritis (OA), degenerative disc disease, cervical and lumbar spondylosis, ataxia, impaired mobility, hypertension, coronary artery disease, peripheral vascular disease, multi-nodular goiter, anxiety, depression, constipation, incontinence, and chronic obstructive pulmonary disease. The patient was admitted to the hospital for COVID-19 pneumonia. She had significant mental and physical decline after COVID-19 infection. She cannot perform most activities of daily living (ADL). The patient complained of fatigue, weakness, has unsteady gait, tendency to fall. Since hospitalization for pneumonia the patient is oxygen dependent, 2L. She has dysphagia and needs assistance with feeding. She also needs assistance with toileting. OA affects patient's hands, knees, ankles. The patient has an unsteady gait, is unable to ambulate without human assistance, has a history of falls, and is at high risk for falls. The physician recommended 12 hours of home care daily, 7days per week.

This patient with an extensive medical history and substantial functional impairment lives alone and needs assistance with all daily activities. Her recent hospitalization resulted in significant mental and physical decline. She cannot recall dates, her address, or DOB; responds "I do not know" to most questions. The patient's decision making capacity for daily tasks has declined to the point where her decisions are consistently poor/unsafe. It is likely that her recent functional decline is at least partly due to cognitive impairment. She had been approved for personal care services (PCS) 43 hours per week. The patient (via designee) requested an increase of PCS to 63 hours per week which was denied; but the insurer increased PCS to 48 hours per week.  

Elderly people with multiple medical conditions and functional impairment often experience functional decline following an acute medical illness. The mental and physical decline from the acute episode does not necessarily resolve completely after the patient recovers from the illness; and when improvement occurs it can be a slow, gradual process. Rehabilitation is usually recommended for patients who have potential for improvement with physical function. The patient needs assistance with all daily activities to ensure proper and safe completion of IADLs and ADLs, and to decrease the chance of adverse outcomes including falls/injuries, skin damage, weight loss/impaired nutrition, and dehydration. Therefore, it is medically necessary for her to have caregiver assistance with all daily activities. The patient's informal caregivers (her daughters) are supportive, but are unable to provide assistance on a daily basis. Assistance from informal caregivers is voluntary as per NYS regulations for PCS. When informal caregivers are not available to provide care on a regular basis, then PCS are indicated to assist the patient with daily activities as needed. 

The request for PCS is for 63 hours per week (9 hours per day). However, there is still concern as to how the patient can safely and properly manage her IADLs and ADLs during the 15 hours she is alone each day. The maximum amount of hours that can be approved from this review is limited by the number of hours requested, i.e. 63 hour per week. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Services 9 hours a day, 7 days a week is substantiated. The insurer's denial is overturned.