Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Advanced dementia.
Treatment:  Personal Care Services 24 hours per day, split shift, 7 days per week.

The insurer denied coverage for Personal Care Services 24 hours per day, split shift, 7 days per week.  The denial is reversed.

This patient is a female with multiple medical conditions and extensive functional impairment, lives alone, and receives assistance through personal care services (PCS) 63 hours per week and informal care from her daughter (UAS indicates daughter primarily assists with IADLs).  A letter from the physician describes recent decline in patient's condition and reported that she is receiving hospice services (at home).  It appears the primary cause of the decline is advanced dementia.  The insurer's final denial letter states the daughter requested PCS 24 hours split shift.  The request was denied.  The insurer increased PCS from 56 to 63 hours per week.  An external appeal was requested by patient advocate.

As per the physician's letter the patient has advanced dementia with recent decline in health and functional status, including weight loss (24 lbs), bladder and bowel incontinence, and recent falls.  The UAS reported significant functional impairment requiring substantial assistance with all IADLs and ADLs.  The patient's physical and mental function as described in the UAS indicate decline from the previous UAS.

It appears that dementia is considered the primary cause of the patient's functional decline.  For a person with dementia, decreasing ability to perform daily activities is an expected consequence of the disease as it progresses.  In general, decreased ability to perform IADLs precedes decline of ADLs; as most IADLs require a higher level of cognitive function.  In the later stages of dementia, ability to perform ADLs also declines.  Most people with advanced dementia also develop incontinence (various causes). 

The patient is receiving hospice care, and it is understood that her condition will most likely decline.  This reinforces the need to have a care plan in place to decrease risk of preventable adverse health and safety events (e.g. falls, incontinence associated skin injury, pressure ulcers) that can cause pain/discomfort and to provide assistance with food/fluids for as long as the patient can safely accept oral intake.  The patient needs assistance for all daily activities, including ADLs that occur at unscheduled and unpredictable times day and night (i.e. transfers, walking, toileting/incontinence care); and bed mobility/repositioning for pressure relief, and for pain relief when needed.  Therefore, it is medically necessary for the patient to have a caregiver present throughout the day and night to provide assistance with ADLs.

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  The only informal caregiver identified in the UAS is the patient's daughter.  She is involved in the patient's care, but there is no documentation to indicate that she can provide consistent and extended hours of care each day or night.  The basis for the insurer's determination of medical necessity for personal care services 9 hours per day, but not for the other 15 hours per day remains unclear.  Without informal caregivers to provide the necessary care, then personal care services are indicated to provide assistance with IADLs and ADLs, including ADLs that occur throughout the day and night.

Personal Care Services 24 hours per day, split shift, 7 days per week are medically necessary.  The health plan did not at reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Services, 24 hours a day split shift x 7 days a week, is substantiated.  The insurer's denial is reversed.