202103-136653
2021
Senior Whole Health of New York, Inc
Managed Long Term Care
Cardiac/ Circulatory Problems
Home Health Care
Medical necessity
Overturned
Case Summary
Cardiac/Circulatory Problems/Congestive Heart Failure/CHF
Treatment: Home Health Care
The health plan denied the requested increase in personal care assistant hours as not medically necessary.
The health plan's determination is overturned.
This is the case of the chronic care of a male who lives alone with congestive heart failure (CHF), emphysema, is oxygen dependent and steroid dependent, has edema, dyspnea, hypertension, urine incontinence, imbalance, walker/wheelchair dependent, with multiple needs including bathing, meal preparation and toileting. He presently has personal care assistance (PCA) for 12 hours per day. The request for 24-hour care has been denied by the insurance plan. The family is seeking 24-hour care.
At issue is the medical necessity of the requested increase in personal care assistant hours.
The health plan's determination of medical necessity is overturned, in whole.
It is this reviewers' opinion that the patient needs full time help to treat his multiple co-morbidities as listed, and his complex polypharmacy including chronic nasal oxygen and immunosuppressive doses of steroids, which cause progressive muscle weakness. His gait is unsteady, and his balance is poor. He needs total assistance for toileting and transferring. He fell and could not get up. He needs continuous PCA services to maintain his health and safety in his home. The standard of care requires 24-hour care as a reasonable treatment in the best interest of the patient. The requested 24 hour per day, split shift PCA service is medically necessary.
After review of the Uniform Assessment System-New York (UAS) that was performed, the patient requires maximum assistance needed for toilet, locomotion and extensive assistance for bed mobility. He is incontinent and his self-sufficiency has declined. Expect further deterioration.