Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, dementia, coronary heart disease, depression, hypertension, urinary and fecal incontinence, muscle weakness, and osteoporosis
Treatment: 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person
The insurer denied coverage for 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person
The denial is overturned

This patient has substantial functional impairment associated with various medical conditions and needs assistance for all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives alone. She had been receiving personal care worker (PCW) services 84 hours per week (12 hours per day). As per the Uniform Assessment System (UAS) report, family provides some informal help with daily activities, and a private hire aide assists the patient at night. The patient requested increase of PCW services to 7 days per week, 24 hours per day: 168 hours per week, continuous care by more than one person. The request was denied; but the plan approved PCW 24 hours per day live-in services. An external appeal was requested.

The functional status report for IADLs indicate patient is totally dependent for meal preparation, ordinary housework, managing finances, shopping; she needs maximal assistance for phone use, stairs, transportation, equipment management; extensive assistance for managing medications. For ADLs, the patient needs maximal assistance for bathing, dressing lower body, toilet use; extensive assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet, eating, bed mobility. Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple medical conditions. Other factors include social and economic circumstances. 

As per New York State (NYS) regulations for personal care services, in order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can expect to have 5 uninterrupted hours of sleep within an 8-hour sleep period each day. If the patient's care needs are of such high frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services are indicated, such as split shift. 

Due to physical and cognitive impairment, the patient needs substantial assistance with all daily activities. Inadequate care can have significant adverse consequences. 

Considering the patient's medical history and functional impairments, it is necessary for the patient to have assistance for all ADLs and IADLs when needed throughout the day and night. Without adequate assistance, the patient is at risk for adverse health and safety events, such as falls/injury; skin damage due to pressure injury and/or inadequate toileting/incontinence care.

The frequency of the patient's care needs does not appear to be compatible with live-in aide services. During day/evening hours, the aide assists with all morning and evening ADLs; meal preparation and service for all meals, assist with eating; all housekeeping tasks; plus assist with toileting/ incontinence care and mobility (walking, transfers, bed mobility) when needed at unscheduled and/or recurring times throughout the day and night. There does not appear to be a clear opportunity for a live-in aide to have 5 uninterrupted hours of sleep per day/night on a regular basis. If a live-in aide does not obtain sufficient sleep, the aide is at risk for personal health and safety problems; and places the patient at risk, as there is greater chance of mistakes and accidents if the aide is working with inadequate rest. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person is overturned. Medical Necessity is substantiated.