Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident.
Treatment: Increase in personal care services to 24 hours a day, 7 days a week (live-in).
The insurer denied the increase in personal care services to 24 hours a day, 7 days a week (live-in).
The denial is overturned. 

This patient is a male with a medical history notable for history of cerebrovascular accident, right hemiparesis, chronic obstructive pulmonary disease (COPD), diabetes, coronary artery disease status post coronary artery bypass graft (CABG) times (x) 4, peripheral artery disease, obesity, heart failure with reduced ejection fraction, and peripheral neuropathy. The patient's care team requested an increase in personal care services to 24 hours per day (live-in). This request was denied by the health plan, who allowed 10 hours per day, 7 days per week (70 hours total per week) of level 2 personal care services.
A letter of support for this appeal is provided by the treating physical therapist. The physical therapy (PT) provider notes that the patient requires maximum assistance for bed transfers and requires standby maximum assistance while using a walker. At most he can do 10 steps with maximum assistance.
The patient was admitted to a Nursing Home and discharged. At the time of discharge, his treating physician wrote a note that due to his weakness, pain, and fatigue, that the patient would need 24/7 assistance to "safely manage his care in the community."
An advocacy report was submitted on behalf of the patient. It details the facts listed above, along with pertinent New York state law regarding the case. Of note, they discuss MLTC Policy 16.07 which requires personal care services adequate to assist with activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. It also specifies explicitly that task-based tools are not appropriate for patients who require 24-hour services due to the unscheduled nature of their needs.
A Uniform Assessment System (UAS) was completed and was available for review. He was noted to require total dependence for meal preparation and housework. He requires maximal assistance for managing medications. He requires maximal assistance for bathing, hygiene, dressing upper and lower body, toilet transfer, toilet use, and eating. He requires total dependence for locomotion. He requires extensive assistance for bed mobility. He is frequently incontinent of urine. He is infrequently incontinent of stool.
At issue is the medical necessity of Increase in personal care services to 24 hours a day, 7 days a week (live-in).

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of increase in personal care services to 24 hours a day, 7 days a week (live-in) is medically necessary for this patient.
This patient has extensive need for assistance in completing nearly all ADL's and IADL's. He has incontinence issues with high frequency and is unable to transfer to the toilet, clean himself, or change into new clothing in the event that he has any loss of urine or stool. This is detailed in the patient advocacy report; this is not a theoretical concern, but one that is actually happening with regularity. Care for these basic ADL's is integral to level 2 personal care, and the hours-based needs assessment is not applicable in a case such as this. Furthermore, if he continues to be left in this state, he will likely develop skin breakdown, bacterial and/or yeast infections, and further medical complications as a result of failure to provide basic care.
Therefore, the requested health service/treatment of Increase in personal care services to 24 hours a day, 7 days a week (live-in) is medically necessary.