Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease, Depression 
Treatment: 91 Hours/Week, Consumer Direct, 1 Client 

The insurer denied 91 Hours/Week, Consumer Direct, 1 Client. The denial was overturned. 

This is a male patient with a medical history of coronary artery disease (CAD), congestive heart failure (CHF), hypertension, hyperlipidemia, type 2 diabetes with neuropathy, pain, depression, hypothyroidism, gastroesophageal reflux disease (GERD), cerebrovascular accident (CVA), gout, osteoarthritis, history of falling, morbid obesity, acute kidney injury (AKI). Several of his medical problems and medications have the potential for various symptoms and adverse effects that could limit his ability for routine daily activities. The patient is dependent on a daily caregiver to assist with all of his activities of daily living due to the chronic symptoms he suffers from. The patient was receiving personal care services (as CDPAS) 28 hours per week. The patient requested an increase to 91 hours per week without overnight services. 

The patient is dependent on caregiver assistance for all household related tasks (IADLs).  He needs maximal or extensive assistance with all ADLs (except eating - supervision).  The patient has multiple co-morbidities that most likely contribute to his decreased ability with IADLs and ADLs. 
 
Chronic pain: The patient describes pain in his lower extremities and back, which is severe at times (pain score 9/10), and associated with various conditions. He has neuropathy, most likely due to diabetes. The patient has advanced CKD, which is also associated with neuropathy. The patient has osteoarthritis, with x-ray of knees showing severe degenerative changes. The patient is obese, which is a risk factor for osteoarthritis of the knees. He also has history of gout; and x-ray showing chondrocalcinosis. Arthritis is a frequent cause of disability due to pain and decreased mobility. Arthritis symptoms (pain, decreased ROM [range of motion]) plus other symptoms (e.g. weakness, fatigue) from co-existing diseases have a cumulative effect resulting in functional impairment.  Pain from arthritis often increases the burden of performing mobility related daily activities. 

A serious concern is the patient's recent falls. He has not had a serious injury from these falls; but he is high risk for recurrent falls, and the risk of injury is always present. The increase of falls may be related to recent stroke, as falls are a common complication of strokes. His risk factors include: chronic pain, arthritis, unsteady gait, stroke, h/o falls, incontinence, use of medications associated with fall risk (e.g. antihypertensive drugs, diuretics). The patient has significant health problems which increase his risk of complications if he has a serious injury. Even relatively minor injuries can cause increased pain and impaired mobility for an extended period of time. 

The patient needs assistance for toileting, and mobility around his home. These activities are not limited to a few hours per day. Therefore, it is medically necessary for the patient to have caregiver assistance for the hours of the day when he is active and out of bed. The patient has some friends who have been providing informal care with meals and ADLs; but it was noted they have health problems. The patient needs assistance with ADLs at various and unscheduled times throughout the day. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services (in this case, CDPAS). The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for 91 Hours/Week, Consumer Direct, 1 Client is overturned. The medical necessity is substantiated.