Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral infarction; Seizures; Parkinson's disease,
 
Treatment: Personal care services

The insurer denied coverage for personal care services 24 hours a day, 7 days a week (live-in) for a total of 91 hours a week. The denial is reversed. 

This patient is a female with multiple chronic medical conditions. She had traumatic brain injury. One physician's note refers to a cerebral hemorrhage; another physician identified a subdural hematoma. It appears the patient had a prolonged recovery for several months before she could return home. The patient's medical and functional status prior to the brain injury is not clear, but there is persistent neurologic dysfunction, in addition to other medical problems.

The patient's mental status as per the late-2019 UAS indicates significant cognitive impairment, with severely impaired memory and decision making capacity. It is not clear how much is directly related to the brain injury, as the UAS from early-2019 indicates patient's decision making capacity was substantially better, and memory was not impaired. Psychiatry notes indicate fluctuating mental status, possibly due to delirium. The neurologist's letter and office note indicate patient has dementia. It appears she also has Parkinson's disease; though there was some uncertainty until she responded poorly to stopping carbidopa-levodopa. The neurologist recommended a drug, nuplazid, which is indicated for delusions and hallucinations associated with Parkinson's disease. The patient's impaired cognitive status adversely affects her ability to participate in her daily activities. The neurologist resumed treatment for Parkinson's disease. This may help to some degree with her mobility.

Based on the patient's medical conditions and functional impairment, it is medically necessary and in the patient's best interest for a caregiver to be present throughout the day and night to provide assistance with ADLs that occur throughout the day and night, and at unscheduled times; i.e. incontinence care, turning and positioning when patient is in bed. The patient's children are involved in their mother's care, but it appears they cannot provide the assistance needed on a consistent basis for extended periods of the day or night. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. When informal caregivers cannot provide reliable and sufficient hours of care, then personal care services are indicated to provide assistance with ADLs.

As per NYS regulations for live-in personal care aides, a person's care needs must be of such frequency that an aide can expect to have at least 5 uninterrupted hours of sleep per day. It is not clear whether the patient's nighttime ADL needs are consistent with the sleep requirements for a live-in aide. The recommendation from this review cannot exceed the amount of services requested; and so PCS 24 hours live-in is approved. Whether this plan of care is sufficient to best serve the needs of the patient and provide adequate rest for the aide; or if additional services (split shift) are necessary will be determined by re-assessment.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the requested personal care services, 24 hours a day, 7 days a week (live-in) for a total of 91 hours a week is substantiated.  The insurer's denial is reversed.