
202205-149610
2022
Molina Healthcare of New York, Inc.
Medicaid
Respiratory System
Home Health Care
Medical necessity
Overturned
Case Summary
Diagnosis: Respiratory System.
Treatment: Home Health Care.
The insurer denied T1019-Consumer Directed Personal Care Services (CDPAS) at 120 hours per week.
The denial is overturned.
The patient is a male with a past medical history is significant for ventilator dependent respiratory failure and quadriplegia. The subject under review is the medical necessity for Consumer Directed Personal Care Services (CDPAS) at 120 hours per week. The patient has been approved for 97.5 hours a week. Additional services were denied by the plan based upon medical necessity.
The requested health service is medically necessary for this patient.
The patient is quadriplegic and ventilator dependent requiring complete care. Even though the patient's nursing assessment noted a total 97.5 hours a week, the patient cannot function for himself independently due to his underlying medical condition. Insurance denied the request for 120 hours a week stating the following, your needs can be met in 97.5 hours per week.
Uniform Assessment System (UAS) State of New York was reviewed.
Patient is quadriplegic and unable to perform any independent functions, Instrumental activities of daily living (IADLs) or activities of daily living (ADLs). He is completely dependent on others for his care. His past medical history significant for stage four (IV) pressure ulcer with a need for frequent turning to prevent breakdown. The patient has no noted active ulcers at this time. The patient is high risk for recurrent pressure ulcer without turning on a regular basis.
The patient has no informal help. His mother has been staying with them until he can be properly cared for. Patients with quadriplegia cannot function independently and need to be turned on a frequent basis to prevent breakdown of the skin, every 2 hours. Based on the information provided the increase to 120 hours a week is medically necessary for this patient's condition.