Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, dizziness, history of falls, muscle weakness, abnormalities of gait and mobility, and macular degeneration
Treatment: Personal Care Services (PCS) 24 hours per day, 7 days a week (split shift) for a total of 168 hours
The insurer denied coverage for PCS 24 hours per day, 7 days a week (split shift) for a total of 168 hours
The denial is overturned 

This female has experienced functional decline due to several chronic medical conditions, with exacerbation due to acute injury and illness earlier this year. The patient lives alone. She needs help with all daily activities and relies primarily on PCS to assist with instrumental activities of daily living (IADLs) and activities of daily living (ADLs). She has been receiving some informal help from two family members during non-PCS hours. The patient receives PCS 49 hours per week, 7 hours per day. The patient requested (via designee) increase of PCS to 24 hours per day, 7 days per week, split shift, which was denied. External appeal was requested.

The most recent Uniform Assessment System (UAS) report was reviewed. The functional status report for IADLs indicates patient is totally dependent for ordinary housework, stairs, transportation; she needs maximal assistance for meal preparation, managing finances and medications, shopping, phone use. For ADLs, she needs maximal assistance for bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use; extensive assistance for personal hygiene, dressing upper body, bed mobility; limited assistance for eating.

The Barthel Index was used to measure and quantify the patient's ADL function; total score 35/100, which is in the range of significant dependency (interpretations of the index place score of 0-20 as total dependency and 100 as total independence). 

PCS 7 hours per day is not sufficient to serve and assist with 3 meals per day. Family members provide some help after PCS hours (it appears that is how the patient has dinner); but the daughter indicated the family is unable to maintain this level of informal care long term. As per information in the UAS and occupational therapy (OT) report, the patient is not capable of safely serving herself a meal, even if it is pre-prepared and in the refrigerator. Her impaired mobility and vision increase risk for falls, kitchen accidents, dropped/spilled food/fluids. When the patient is alone and experiences pain, fatigue, weakness, it may be easier to skip a meal. The patient's physical, sensory, and cognitive impairment place her at risk for nutritional decline and dehydration. She needs a caregiver to assist with food and fluids from morning to evening. 

Assistance from informal caregivers is voluntary, as per New York State regulations for PCS. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed. The records provided for review indicate the level of care and frequency of care the patient requires for ADLs and IADLs support the need for PCS 24 hours per day split shift.

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 PCS 24 hours per day, 7 days a week (split shift) for a total of 168 hours is oveturned. Medical Necessity is substantiated.