Diagnosis: Heart disease, diabetes mellitus, hyperlipidemia, gastroesophageal reflux, osteoarthritis, stress incontinence, and glaucoma.

Treatment: Social Daycare Service (SDC) 2 days per week.

The insurer denied coverage for Social Daycare Service (SCD) 2 days per week.

The denial is upheld.

The patient has a history of heart disease, diabetes mellitus, hyperlipidemia, gastroesophageal reflux, osteoarthritis, stress incontinence, and glaucoma. Uniform Assessment Score (UAS) shows she is able to walk with the use of a cane. She is able to bathe and dress with limited assistance. She is able to manage personal care transfer on and off the toilet and use the toilet without any physical assistance. She is independent in bed mobility. She receives personal care services (PCS) and SDC. The request is to increase SDC to 2 days per week.

The New York State Office for the Aging Adult Social Daycare Services cite notes:

"... person who needs the assistance of another person in at least one of the following activities of daily living: toileting, mobility, transferring, or eating; or who needs supervision due to cognitive and/or psycho-social impairment. ..."

These needs are not documented as being active. There is no rationale given for the need for a second day of Daycare services.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Social Daycare Service (SDC) 2 days per week is upheld. Medical necessity is not substantiated.