Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, atrial fibrillation, hypertension, Parkinson's disease, anemia, pancreatic cancer, osteoarthritis, deep vein thrombosis, and open-heart surgery.

Treatment: Home care/personal care Health and Home Care (HHC) level 2 personal care services (PCS), per 15 minutes increase to 24 hours per day (split shift).

The insurer denied coverage for home care/personal care HHC level 2 PCS, per 15 minutes increase to 24 hours per day (split shift).

The denial is overturned.

This female has complex medical history associated with functional decline requiring assistance for all daily activities. She lives alone and receives some informal support from family, but she mostly relies on PCS for assistance with activities of daily living (ADLs) and instrumental ADLS (IADLs). The Uniform Assessment System (UAS) indicate patient receives PCS as Consumer Directed Personal Assistance Services (CDPAS). A more recent UAS indicated patient was receiving CDPAS 45 hours per week. The patient requested 24 hours per day split shift services, which was denied, but the plan approved 24 hours per day live-in services. Plan appeal for split shift services was denied. An external appeal was requested.

Functional decline (physical and cognitive) in the elderly is usually the result of cumulative and interactive effects of multiple medical conditions. Other factors include social and economic circumstances such as 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. The patient has multiple medical conditions, including diagnosis several months ago of pancreatic cancer followed by surgery. She is currently receiving chemotherapy, and so effects of the disease and the treatment probably contribute to her current weakened status and possibly to cognitive changes.

The patient is experiencing a physically stressful situation due to side effects of chemotherapy, possible symptoms related to pancreatic cancer such as fatigue and weakness and exacerbated by chronic pain. It is medically necessary, and in the patient's best interest for a caregiver to be present and awake to provide ADL/IADL care when needed throughout the day and night. This can help prevent or minimize occurrence of new (avoidable) medical problems. The patient's current medical and functional status requires caregiver assistance with toileting/incontinence care, repositioning, and assistance with medication for symptom relief throughout the day and night to help prevent skin injury, infection, aspiration; and help with pain relief.

Considering the time needed for IADLs (housekeeping, meal preparation/service, medications) and routine ADLs (bathing, personal hygiene, dressing), plus ADL care at unscheduled and recurring times of the day/night (toileting/incontinence care, bed mobility/positioning), the patient's care needs do not appear compatible with the schedule of a live-in aide, as there does not appear to be a clear opportunity for the aide to have 5 hours of uninterrupted sleep on a daily basis, as required by state regulations for live-in aides. Therefore, PCS/CDPAS 24 hours per day continuous services (split shift) is necessary. 

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 home care/personal care HHC level 2 PCS, per 15 minutes increase to 24 hours per day (split shift) is overturned. Medical Necessity is substantiated.