Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD), diastolic heart failure, hypertension

Treatment: Increase in personal care services to 24 hour times 7 days - (Live-In)

The insurer denied coverage for increase in personal care services to 24 hour times 7 days - (Live-In). The denial is reversed.

This patient is a male who has the following medical conditions: chronic obstructive pulmonary disease (COPD), diastolic heart failure, hypertension, arterial sclerotic heart disease (ASHD), chronic kidney disease (CKD), kyphosis, Alzheimer's disease, osteoporosis, enlarged prostate with lower urinary tract symptoms (LUTS), dizziness, malnutrition. Because of his deteriorating condition he is at risk for falls and has fallen several times in his apartment. The patient is incontinent of bowel and bladder. When he uses the toilet or commode he needs extensive assistance transferring on and off. He needs assistance to get off the bed. He uses diapers when the toilet or commode is not possible. He needs a diaper change at least twice through the night. Patient needs help with hygiene on the toilet and with diapers. He cannot perform these tasks himself and his wife is unable to assist him. The patient needs personal care services increased to 24 hours.

The patient also has bowel incontinence. The cause is not noted, but as with urinary incontinence, it can be due to inability to reach the toilet in time. Based on the physician's report, incontinence is one of the main reasons the patient needs caregiver assistance at night. The patient is not able to transfer himself to the commode unassisted (transfer toilet: maximal assistance per UAS). He wears pads or diapers at night. It is reasonable to expect that an advanced aged man with BPH will need to urinate more than once in 12 hours. If he cannot use the toilet/commode and he has episodes of incontinence, then he is confined to bed with wet, soiled diapers, and possibly soiled bed linens and clothes until the PCA returns in the morning. This is an inadequate plan of care that not only results in discomfort for the patient, but creates significant risk for incontinence associated skin injury (e.g. dermatitis, fungal infection, pressure ulcers). The patient's wife is not capable of providing assistance (as per physician) and the patient has no other informal helpers (as per UAS) when the PCA leaves each day.
                                                                                     
Regarding falls, based on the UAS it appears the patient does not walk as part of his daily routine. It is not known whether he still has the strength to get up from bed or a chair and attempt to walk (UAS indicates he is unable or has difficulty standing up unassisted). If he does make the effort, there is substantial risk for falls (risk factors include pain, weakness, poor safety awareness, prior history of falls). Falls in the elderly carry an increased risk of serious injury (e.g. fractures, head trauma) and substantial morbidity.

The patient has no informal caregiver in the home all night who can provide assistance. Caregiver assistance is medically necessary to provide the patient with ADL care, as the patient has multiple medical conditions and functional limitations that interfere with safe and proper self-performance of ADLs. In the absence of informal caregivers, then it is medically necessary for personal care services to provide assistance. The request was made for 24 hour live-in. As per NYS regulations for live-in personal care aides, it is required that the aide should have at least 5 uninterrupted hours of sleep per day. 

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 an increase in personal care services to 24 hour times 7 days - (Live-In) is reversed.  The medical necessity is substantiated.