Appeal type: Medical necessity
Decision: Overturned

Diagnosis: falls, generalized osteoarthritis, abnormalities of gait and mobility, functional urinary incontinence, flaccid hemiplegia affecting left nondominant side, and chronic pain.

Treatment: increase in personal care worker (PCW) services from 7 days per week, 4 hours per day; 28 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 7 days per week, 4 hours per day; 28 hours per week to 7 days per week, 24 hours per day, live in; 91 hours per week.

The denial is overturned.

This case involves a geriatric patient who received partial denial of coverage for an increase in personal care worker (PCW) services from 7 days per week, 4 hours per day; 28 hours per week to 7 days per week, 24 hours per day, live in; 91 hours per week. 

A Uniform Assessment System for New York (UAS-NY) noted that the patient lives alone in an apartment home and needed help with care at home. The assessment noted the patient required limited to maximal assistance with certain activities to include activities of daily living and meal preparation as well as with transportation, shopping, and navigating stairs. The report stated the patient's symptoms had deteriorated in terms of self-sufficiency compared to 90 days prior. The patient had suffered 2 or more falls in the last 30 days and exhibited dizziness and unsteady gait in the last 3 days. The patient reported mild pain, daily tobacco smoke, with 1 emergency room visit. Records stated the patient had a diagnosis of chronic obstructive pulmonary disease and coronary heart disease along with neoplasia. Overall, the patient was found to have modified independence with some difficulty in new situations only. The patient's memory was okay, and it was determined that the patient ambulated with no assistive devices, required limited assistance with certain activities. An updated UAS-NY noted the patient lives alone in a one-bedroom apartment on the fourth floor. The patient had modified independence with some difficulty in new situations only, had intact memory with adequate hearing and vision. The patient was found to require limited to maximum assistance with functional activities. The report indicated that the patient's overall self-sufficiency had significantly declined in the last 90 days. The patient was observed transferring and ambulating with a hemi walker and contact-guard given his left hemiplegia. The patient continued to display dizziness and an unsteady gait and suffered a fall from bed whereupon the patient was transferred to the hospital. The report indicated the patient satisfied the need for 120 days continue with services with more than 2 activities of daily living (ADLs) at limited assistance level or above. It was determined that the patient met 19 points of nursing facility level care.

Personal care services allow patients to remain in the comfort of their own home rather than receiving treatment in a skilled nursing facility or in assisted living. The documentation provided for the review noted the patient was authorized for an increase in personal care worker services from 28 hours a week to 42 hours a week. However, there were changes noted on the assessment to suggest that the patient required additional care for safety reasons. The partial denial of coverage was not appropriate as the patient needs 24-hour care given the increased risk of falls. 

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 7 days per week, 4 hours per day; 28 hours per week to 7 days per week, 24 hours per day, live in; 91 hours per week is substantiated.