Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, chronic obstructive pulmonary disease, cardiovascular disease

Treatment: Personal Care Services (PCS) of 10 hours per day, 7 days per week for a total of 70 hours per week

The insurer denied coverage for Personal Care Services (PCS) of 10 hours per day, 7 days per week for a total of 70 hours per week

The denial is overturned

This elderly female has medical conditions that likely contribute to her functional impairment including chronic obstructive pulmonary disease, cardiovascular disease, and osteoarthritis. She fell and was admitted to the hospital for a right pelvic fracture. After a period of rehabilitation (rehab), she was sent home from a skilled nursing facility (SNF) at which time she tested positive for novel coronavirus (COVID-19). Discharge Physical Therapy (PT) and Occupational Therapy (OT) plan indicated patient needed supervision for walking, transfers, stairs, bathing, upper body dressing, toileting. 

The patient lives alone and mostly relied on the assistance from Personal Care Services (PCS). She received PCS, 5 hours per day, 7 days per week (35 hours per week). An increase of PCS to 10 hours per day, 7 days per week (70 hours per week) was requested.
Per the New York State Department of Health's Uniform Assessment System (UAS-NY) done some time after discharge, significant changes were noted in the patient's level of function. The UAS (Uniform Assessment System) indicated functional decline for most activities of daily living (ADLs). Regarding instrumental activities of daily living (IADLs), the patient was totally dependent for housework; needed maximal assistance for meal preparation and shopping; extensive assistance for managing finances and medications, transportation, stairs.

The patient has frequent urinary incontinence. Considering she needs significant assistance with toilet use and lower body dressing, it is reasonable to expect that she needs assistance with incontinence care. She takes diuretics which increase frequency of urination, and the physician noted patient has overactive bladder. When there is an immediate need to reach the toilet, transfers and walking are often done in haste and with less regard for safety, which also increases the risk for falls. 

The patient has history of falls. Her risk factors for falls include arthritis, lower extremity pain, dizziness, incontinence, cognitive impairment, advanced age, history of falls, use of medications associated with fall risk (e.g., antihypertensive drugs, diuretics). For this patient, preventing falls is a priority, as she has significant cardiopulmonary disease which can increase risk of complications. 

MLTC (Manage Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, the patient's need for assistance with transfers, walking, toileting, incontinence care that occurs at various times throughout the day must be considered in the determination of the patient's personal care service hours.

Based on the information provided for review, the patient needs assistance with activities that occur at routine and unscheduled times during the day, and the care plan needs to accommodate these care needs. It is medically necessary, and in the patient's best interest to have a caregiver present over a longer period of time each day to provide assistance with daily activities in order to help prevent adverse health and safety events, such as falls/injury; skin damage and urinary tract infection from inadequate toileting and incontinence care; impaired nutrition; dehydration.

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

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 Personal Care Services (PCS) of 10 hours per day, 7 days per week for a total of 70 hours per week is overturned. Medical necessity is substantiated.