Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD).
Treatment: Social day care daily: 1 day(s) - 2 day(s) per week - a total of 2 days per week is medically necessary for this patient.
The insurer denied: Social day care daily: 1 day(s) - 2 day(s) per week - a total of 2 days per week is medically necessary for this patient.
The denial is: Overturned

The patient is a female with past medical history of chronic obstructive pulmonary disease (COPD), benign positional vertigo, osteoarthritis, urinary incontinence, neuropathy, hypertension, gastroesophageal reflux disease (GERD), diabetes mellitus (DM) Type 2, and hypothyroidism who had been approved for social day care 2 days per week. The health plan sent an approval notice stating the patient had been approved for social daycare to total 2 days/week and her care would be reviewed again. The insurer sent initial adverse determination notice to reduce, suspend or stop services stating the plan approval for social daycare 2 days/weekends. The note stated the patient was currently receiving 9 hours/day, 7 days/week of Personal Care Assistance (PCA) services with social daycare services 2 days/week. The denial also stated the social daycare services that the patient was receiving were overlapping with the patient's personal care services and per New York State Department of Health guidelines social daycare services cannot substitute for personal care services the patient requires to support her physical needs.

The family and patient appealed denial decision.  The patient's daughter provided a letter stating the patient did not have overlap of social daycare with PCA services, specifically that the patient had PCA services 9 AM to 6 PM Sunday, Monday, Tuesday, Thursday, and Saturday while 1 PM to 10 PM on Wednesdays and Fridays. The patient attended social daycare on Wednesdays and Fridays. The daughter's letter also stated the patient needed social interaction and cognitive stimulation which was extremely important to prevent anxiety and depression symptoms. The patient's primary care provider sent a letter stating the patient had multiple medical problems with worsening forgetfulness and increased episodes of depression and the provider strongly recommended social daycare to prevent progression of forgetfulness and depressed mood.

The health plan's determination is overturned.

The social day care daily: 1 day(s) - 2 day(s) per week - a total of 2 days per week is medically necessary for this patient. The patient's medical provider documented medical necessity of social daycare given the patient's dementia and depression. In addition, the universal assessment demonstrated the patient had assistance needs with all tasks except for eating and therefore would require assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) outside of the time she has informal help. The patient's daughter indicated that there was no overlap of social daycare with personal care service hours. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, social day care 1 day(s) - 2 day(s) per week - a total of 2 days per week are medically necessary for this patient. Personal care services and social day care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety.