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202202-146360

2022

VNSNY CHOICE Health Plans

Managed Long Term Care

Orthopedic/ Musculoskeletal, Mental Health

Home Health Care

Medical necessity

Overturned

Case Summary

Diagnosis: Lumbar spinal stenosis with radiculopathy, osteoarthritis of knee, osteoporosis, and anxiety/depression.
Treatment: Increase Personal Care Services, Total of 84 Hours (12 Hours a Day, Seven Days a Week).

The insurer denied the Increase Personal Care Services.
The denial is overturned.

This female patient has conditions including lumbar spinal stenosis with radiculopathy, osteoarthritis of knee, osteoporosis, and anxiety/depression. She is appealing denial of increase personal care services (PCS), total of 84 hours. The health plan approved 42 hours.

An appeal letter from Advocacy reports the patient has limitations that require 24 hours assistance. The patient had multiple falls over the past six months, including a trip over her walker and fell. Her family is ensuring 12 hours of personal care daily. Her provider wrote a letter of medical necessity due to the patient's functional needs and falls occurring at night. Her provider notes the patient has frequent falls when left alone. A daily schedule shows the patient receives care 24 hours.

A letter from the physician notes the patient lives in assisted living and needs 24 hour care due to functional limitations. The letter notes the patient has many falls during the night.

A Daily Schedule Log provided shows the patient receiving assistance approximately every one hour with transfers and activities of daily living (ADLs).

Yes, the proposed treatment, increase in Personal Care Services, Total of 84 Hours (12 Hours a Day, Seven Days a Week), is medically necessary.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. She is appealing denial of increase in personal care services, total of 84 hours. The health plan approved 42 hours. Uniform assessment system (UAS) evaluation completed, shows the patient requires assistance with all activities of daily living, except personal hygiene, bed mobility, and eating. She has bowel and bladder incontinence. Appeal statements note the patient requires 24 hours assistance due to functional limitations. There is a daily schedule that supports the patient receiving care during the day and nighttime to include assistance approximately hourly. The approved personal care services 42 hours per week is inadequate to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care. The proposed increase in personal care services to total 84 hours per week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

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