Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive decline
Treatment personal care services of 15 hours per day, 5 days per week and 10 hours per day, 2 days per week for a total of 95 hours per week
The insurer denied coverage for personal care services of 15 hours per day, 5 days per week and 10 hours per day, 2 days per week for a total of 95 hours per week
The denial is overturned

This male has dementia associated with substantial cognitive decline and severely impaired functional status. He is dependent on caregivers for all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). He lives with his daughter who is his primary caregiver. She was on leave of absence from work for a while to take care of her father, but she had to return to work. The patient had been receiving personal care services (PCS) 65 hours per week. The daughter requested an increase to 95 hours per week which was denied, but services were increased to 70 hours per week.

The most recent New York State Department of Health's Uniform Assessment System (UAS-NY) provided for review. The patient's functional status report indicates the patient is totally dependent for all IADLs except medications (maximal assistance). For ADLs, it was noted that the patient no longer walks, and is not transferred to the toilet (no bladder or bowel control). His mobility is via wheelchair, and he depends on others to propel the wheelchair. For most other ADLs, the patient needs maximal assistance; except bed mobility and eating (extensive assistance). It was noted in the UAS that the patient's ADL status and self-sufficiency declined.

The patient has dementia which is probably a substantial cause of his declining functional status. Based on the UAS information (with history from the daughter) and hospice physician's letter, it appears the patient has moderate to advanced dementia. As per the UAS, the patient's decision-making ability for daily tasks is consistently poor/unsafe. He has extensive memory loss and confusion. It is noted that his ability to communicate is limited to simple requests and responses. During the video/telephonic UAS, he did not respond to any questions from the nurse and did not respond to his name. 

Considering the information provided for review, it is apparent that the patient is dependent on caregiver support for all ADLs and IADLs including routine daily tasks (e.g., meal preparation, bathing, dressing, personal hygiene), and ADLs that occur at various, unscheduled and recurring times throughout the day and night, including incontinence care, turning/repositioning, and assisting with food and fluid over extended periods of time during the day. 

The daughter is requesting an additional 3 hours per day, 5 days per week for a total of 95 PCS hours per week; with additional assistance provided by the daughter (or other informal caregiver) for the other non-PCS hours of the day/night. This is fully consistent with NYS regulations for personal care services and MLTC (managed long-term care) policy 16.07.  

There was sufficient evidence to support that Personal Care Services 15 hours per day, 5 days per week, and 10 hours per day, 2 days per week, total of 95 hours per week was considered medically necessary treatment for the patient's condition.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Services of 15 hours per day, 5 days per week and 10 hours per day, 2 days per week for a total of 95 hours per week is overturned. Medical necessity is substantiated.