Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depression.
Treatment: Social Day Care (SDC) services: daily for 3 days a week for a total of 3 days per week.
The insurer denied Social Day Care (SDC) services: daily for 3 days a week for a total of 3 days per week.
The health plan's determination is overturned.

The patient is a male with a past medical history of coronary artery disease, major depression, hypertension, fecal urgency, gastroesophageal reflux disease (GERD), hyperlipidemia, hypothyroidism, osteoarthritis, hearing loss and urinary incontinence. He had been assigned social day care services for two hours per week. The patient had undergone a universal assessment via video assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping. He required extensive assistance with stairs and transportation. With the tasks of managing finances, bathing, dressing upper and lower body, toilet transfers, and toilet use the patient was assessed at limited assistance. He required supervision with the tasks of managing medication, walking, locomotion, and eating. The patient was assessed as set up with the task of phone use and he was independent with the task of bed mobility. 

The insurer sent initial adverse determination denial notice denying request to increase social day care services to 3 days per week stating there was no change in the patient's functional status that would necessitate a change in plan of care. The denial also stated the patient's current status does not support a need for increasing the patient's social day care services. The insurer sent a final adverse determination denial notice denying request to increase social day care services stating the patient had personal care assistant (PCA) services 4.5 hours per day, 6 days per week and the New York State (NYS) Department of Health regulations do not allow social day care to represent the primary form of service offered to managed long term care (MLTC) members.

The patient's primary care physician (or provider) (PCP) provided a letter stating the patient's mental and physical conditions had noticeably deteriorate, particularly, the patient lived alone and was very lonely and depressed. The provider noted the patient was unable to perform routine daily living activities as before and due to the patient's medical and physical conditions the patient would feel better and safe around people (family and day care). Lastly, the provider asked the insurer to re-evaluate the case and to consider an increase in day care center hours and failure to provide regular and timely care may result in a scenario of reduced safety for the patient.

The patient provided a letter stating that his retirement in 2002 was a hard blow to his mental and psychologic condition and his wife died 4 years ago and he had been struggling to be alone. The patient noted that his children do not live nearby. He noted that his bright spot of the week was attending 2 mornings of adult daycare as he is able to have a good breakfast and to eat with other people. The patient also noted there are concerts, lectures, and excursions at the adult center and he is very grateful for the 2 mornings he has at the adult daycare but was hoping to attend another day to help with his loneliness and depression.

Social Adult Day Services is a structured, comprehensive program that provides functionally impaired adults (those who need help with everyday tasks) with an array of services in a protective setting for any part of the day, but for less than a 24-hour period. Each participant receives services in accordance with an individualized service plan that is based on an assessment of the individual. A member is eligible if they need the assistance of another person in at least one of the following activities of daily living: toileting, mobility, transferring, or eating; or who needs supervision due to cognitive and/or psycho-social impairment.