Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease (CAD), hypertension, osteoarthritis,

Treatment: Social Day Care (SDC) services, for a total of 1 day per week

The insurer denied coverage for SDC services, for a total of 1 day per week

The denial is overturned

This adult female with a history of major depressive disorder (MDD), coronary artery disease (CAD), hypertension, osteoarthritis, toe bunions, and osteoporosis. She has functional impairment associated with several medical conditions. She needs assistance for all instrumental activities of daily living (IADLs) and activities of daily living (ADLs). NYS Office for the Aging indicates eligibility for social adult day services is a person who needs assistance of another person in at least one of the following activities of daily living: toileting, mobility, transferring, eating; or who needs supervision due to cognitive and/or psychosocial impairment. 

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

Functional decline in the elderly is usually the result of cumulative and interactive effects of various medical conditions. Other factors include social and economic circumstances (e.g., caregiver support). Several of the patient's medical conditions probably have adverse effects on her daily function. 

The UAS describes patient's cognition as follows: Decision making for tasks of daily life was reported as minimally impaired; in specific situations, decisions become poor or unsafe; cues/supervision needed at those times. She was oriented x 3 (person, place, and time); but patient reported she has episodes of confusion to place and time. It was also noted she is forgetful, with short term memory problem. The patient is self-directing. She is able to activate personal emergency response system (PERS) and call family in case of emergency.

SDC could serve as a useful component of the patient's treatment plan, in addition to medication, counseling. The patient indicated that her depressed mood is at least partly due to the combined effects of her health problems, her concern for other family member's health, and her isolation. Engaging in activities outside the home with other people could have beneficial effects on the patient's mental health; and is fully consistent with the purpose of one of the required services for SDC, i.e., engaging in social interaction with other people; and socialization to utilize the participant's physical and mental skills and capabilities and enhance the sense of usefulness and self-respect.

Based on this information, the patient meets eligibility criteria for SDC based on need for ADL assistance; and need for socialization. SDC staff can provide assistance with ADLs when the patient attends SDC (in addition to 6.5 hours PCA services at home); and the social environment and participation in activities can be a useful addition to the patient's treatment plan for depression and anxiety. Therefore, it is medically necessary, and in the patient's best interest to receive social day care services.

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 the social day care (SDC) services, for a total of 1 day per week is overturned. Medical Necessity is substantiated.