Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, Parkinson's Disease, visual hallucinations, angina pectoris, dizziness and giddiness, coronary heart disease, heart failure, depression, tremors
Treatment: increase in personal care worker (PCW) services from 6 days per week, 6 hours per day; 36 hours per week to 7 days per week, 24 hours per day, live-in; 91 hours per week
The insurer denied coverage for increase in personal care worker (PCW) services from 6 days per week, 6 hours per day; 36 hours per week to 7 days per week, 24 hours per day, live-in; 91 hours per week.
The denial is overturned.

This elderly female has experienced functional decline related to chronic and acute medical conditions and needs assistance with all daily activities. The patient lives with her daughter and son-in-law who provide some informal help, but the patient relies primarily on personal care worker (PCW) services for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient had been receiving PCW services 36 hours per week. 

The most recent Uniform Assessment System for New York (UAS-NY) provided for review. The functional status report for IADLs indicate the patient is totally dependent for ordinary housework; she needs maximal assistance for meal preparation, shopping, managing finances; extensive assistance for managing medications, phone use, stairs, transportation. For ADLs, the patient needs maximal assistance for bathing, dressing lower body; extensive assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, eating; limited assistance for bed mobility. 

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple medical conditions. Other factors include social and economic circumstances (e.g., caregiver support). Accelerated periods of decline can occur in response to new/acute medical events. As people age, functional reserve decreases; and when a new medical problem results in further functional decline, it becomes increasingly difficult to return to the prior level of function. 

As per New York State (NYS) regulations for live-in services, the aide needs time for 8 hours of sleep per day, which includes 5 uninterrupted hours of sleep. As per the Uniform Assessment System (UAS), the daughter reported the patient needs help during the night with toileting. She also needs help with repositioning in bed (as per daughter, patient needs limited to extensive assistance). It may be possible for the aide to sleep earlier in the evening when the family is awake and able to assist the patient for a few hours until they go to sleep; then the aide can provide care through the night. Re-assessment will determine whether live-in services adequately meet the patient's daily care needs, or if modification of the plan is needed.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an increase in personal care worker (PCW) services from 6 days per week 6 hours per day; 36 hours per week to 7 days per week, 24 hours per day, live-in; 91 hours per week services is substantiated.