Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multilevel Lumbar Spinal Stenosis, Laminectomy Syndrome

Treatment: Increase in Personal Care Services, Level 2 to 12 hours per day, 7 days per week, total 84 hours per week

The insurer denied the increase in Personal Care Services, Level 2 to 12 hours per day, 7 days per week, total 84 hours per week. 

The denial was overturned.

This is a female patient who was status post-laminectomy syndrome, multilevel lumbar spinal stenosis, diffuse lumbar degenerative disc disease with generalized osteoarthritis. It was reported that the patient had fallen and resulted in severe worsening of pre-existing low back pain. The patient has an aide 7 hours per day, 7 days per week. The patient has medical necessity for an aide 12 hours per day. Request is made to increase aide hours to 12 hours per day, 7 days per week. Her medical history includes coronary heart disease, hypertension, hypercholesterolemia, hypothyroidism, GERD, anxiety, osteoarthritis, osteoporosis, intervertebral disc displacement lumbosacral region, spinal stenosis sacral and sacrococcygeal region, chronic pain, dizziness, difficulty walking, tremor, urge incontinence, constipation
It was reported that the patient lives alone in an apartment and requires assistance for most daily activities. It appears that a substantial cause of her functional impairment is associated with symptoms related to arthritis, degenerative disc disease, spinal stenosis; and exacerbated by a fall. 

The patient needed assistance with most ADLs and IADLs as reported from the UAS report from 2019. As a result of the fall and increased back pain described by her physician, it is reasonable to expect that the patient could benefit from additional assistance with daily activities. As a result of chronic back and lower extremity pain, the patient needs assistance with transfers, walking and toileting, which occur at various and unscheduled times throughout the day. Her PCS hours at that time were 7am-2pm daily. It is likely that the patient has a reason for needing an aide as early as 7am each day (possibly for morning use of the toilet), and so with the aide starting so early, the patient is alone by 2pm. The UAS indicated the daughter assisted the patient in the evening but it is not known whether this plan is still in place. Even if the daughter continues to provide evening assistance, the patient is still alone for several hours until the daughter arrives in the evening. That UAS did not identify any other informal helpers. Assistance from informal caregivers is voluntary, as per NYS regulations for persona
care services. It is medically necessary for the patient to have a caregiver present to provide assistance with ADLs and IADLs throughout the day. In the absence of informal caregivers who can provide necessary care on a regular basis, then personal care services are indicated to provide the patient with assistance for ADLs and IADLs when needed, including ADLs that occur throughout the day at various unscheduled times (walking, transfers, toileting).

This raises another concern, i.e. does the patient needs assistance at night. It appears unlikely that the patient does not need to use the bathroom through the night until the aide returns in the morning; or she may need to get out of bed for other reasons. If she is not getting out of bed to use the toilet at night, then she may be having episodes of incontinence in bed; and if so, how is she managing incontinence care.  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 the requested increase in Personal Care Services, Level 2 to 12 hours per day, 7 days per week, total 84 hours per week is reversed.  The medical necessity is substantiated.