Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, osteoarthritis, osteoporosis
 
Treatment: Consumer and Self-Directed Personal Care Services 

The insurer denied the Consumer and Self-Directed Personal Care Services 12 hours a day, 7 days a week for a total of 84 hours. The denial was reversed.   

This is an elderly female patient with a medical history that includes dementia, epilepsy, anxiety, osteoarthritis, osteoporosis, urge incontinence, insomnia, h/o falling, autonomic neuropathy, chronic sinusitis, spinal stenosis (cervical, thoracolumbar region), radiculopathy lumbosacral region, cervical disc disorder C6-C7 with radiculopathy, carpal tunnel syndrome bilateral, tarsal tunnel syndrome bilateral, dizziness, disorder of optic disc. Due to the patient's failing medical conditions a request for an increase in her personal care services was made. The patient has dementia, and based on available information it appears that the disease is at an advanced stage and is a significant factor contributing to patient's functional impairment. For a person with dementia, decline of functional ability for ADLs and IADLs is an expected consequence as the disease progresses. Based on description in the UAS from late 2019 the patient has very limited communication skills, cannot make her needs known; decision making capacity is poor.  She has significant behavioral problems including resistance to care, easily angered, hits and throws things at caregivers. She has hallucinations and is reported to see and talk to people who are not present. She has history of wandering. Her medications reflect these complications, as she is taking risperidone and trazodone, most likely for behavioral problems and sleep disturbance. She is also taking memantine, donepezil and rivastigmine. Efficacy of these drugs for the patient is not known.

There are other medical problems that are identified in the UAS and in the neurologist's office note that also appear to contribute to patient's functional decline. The patient has history of osteoarthritis. There are limited details available, but in the neurologist's note there is reference to increasing right knee pain, which has been evaluated by orthopedist (no records of this evaluation available). The description of the knee by the neurologist was pain, swelling, redness and warmth. It is not known if this is an acute event or exacerbation of a chronic problem. Records also indicate spinal stenosis (cervical to lumbar) and radiculopathy of lumbosacral and cervical region. These conditions can cause significant pain and disability of upper and lower extremities. It is not known if any of these conditions are currently causing symptoms. 

The UAS indicates the patient has limited range of motion (ROM) of her left arm and leg. The cause is not clearly identified. Restricted ROM of an arm and leg can result in substantial decline in mobility and ability to perform daily activities including walking, transfers and activities requiring ROM of upper extremity (e.g. bathing, dressing, toileting). The UAS also notes that patient has tremors. No cause is identified. Tremors can affect any activity requiring manual dexterity. This may be part of the reason the patient needs to be fed.

Based on the functional needs of the patient as described in the UAS, it is medically necessary for the patient to have caregiver assistance for ADLs that occur throughout the day and night. Assistance from informal caregivers is voluntary per NYS regulations for personal care services. The daughter works long hours and apparently there is not a reliable caregiver who can assist the patient when the daughter is not home.

The health plan did not act reasonably with sound medical judgment.

Based on the above, the medical necessity for consumer and self-directed personal care services 12 hours a day, 7 days a week for a total of 84 hours is substantiated. The insurer's denial is reversed.