Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Coronary heart disease; hypertension; hyperlipidemia.
Treatment:  Personal Care Services 10 hours per day, 7 days per week, total of 70 hours per week.

The insurer denied coverage for Personal Care Services 10 hours per day, 7 days per week, total of 70 hours per week.  The denial is overturned. 

This patient is a female, who lives in assisted living facility.  She has extensive medical history causing physical and cognitive impairment resulting in functional decline.  The patient has been receiving personal care services (PCS) 33 hours per week to assist with ADLs and some IADLs.  Assisted living staff manages meals and medications.  The patient has had multiple falls in recent months, as reported in the physician notes, the UAS and information provided by the patient's son.  The son also reports patient's dementia is getting worse.  He requested increase of PCS to 70 hours per week (10 hours per day), which was denied by the insurer.  The son requested an external appeal.

The UAS functional assessment indicates patient needed extensive or maximal assistance with most IADLs; except phone use (limited assistance).  For ADLs the patient needed extensive assistance with bathing and limited assistance for most other ADLs, except toilet use and eating (independent setup help).  Functional decline in the elderly typically results from the cumulative effects and interactions of multiple medical conditions. 

The UAS and physician notes identify various medical problems that most likely have a significant adverse effect on the patient's functional ability for daily activities. The patient is at high risk for falls when she is out of bed and active.  Some daily activities are time limited and can be scheduled (e.g. bathing, dressing).  The patient also needs assistance with activities that occur at various and unscheduled times throughout the day (i.e. transfer, walking, toileting).  Therefore, it is medically necessary for the patient to have a caregiver present throughout the day (when she is out of bed and most active) to provide assistance with these activities.  

The staff at the assisted living facility provides the residents with some help for IADLs and ADLs but do not provide one to one attention and assistance throughout the day.  With the PCS aide present for 4-5 hours per day, the patient is alone for most of the day.  The available records do not identify informal caregivers, who can provide assistance to the patient for extended periods of time each day at the assisted living facility.  Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services.  Without informal caregivers who can provide help to the patient on a consistent daily basis personal care services are indicated to provide the necessary assistance with daily activities throughout the day when needed.

The patient's medical conditions contribute to physical and cognitive impairment that limit her ability to safely and effectively perform most IADLs and ADLS.  The patient's difficulty with mobility related activities places her at substantial risk of harm.  The patient has had multiple falls over the past 6 months, including head trauma.  It is medically necessary for the patient to have assistance with mobility throughout the day to provide stability and help decrease risk of falls.  The UAS noted that the patient gets out of bed at night and leaves her room.  It appears the staff at the assisted living facility help her back to her room; but the patient's nighttime behavior will need to be assessed to determine needs.

Personal Care Services 10 hours per day, 7 days per week, total of 70 hours per week is medically necessary.

The carrier's denial of coverage for increase in personal care services is overturned.  The medical necessity is substantiated.