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202208-152484

2022

VNSNY CHOICE Health Plans

Managed Long Term Care

Cardiac/ Circulatory Problems

Inpatient Hospital

Medical necessity

Overturned

Case Summary

Diagnosis: Diabetes, hypertension, coronary artery disease (CAD), dementia, and arthritis
Treatment: Increase in personal care services (PCS), 24 hours a day (live-in), 7 days a week, a total of 91 hours a week
The insurer denied the increase in personal care services (PCS), 24 hours a day (live-in), 7 days a week, a total of 91 hours a week.
The denial is overturned.

This elderly female has extensive medical history associated with functional impairment. The patient lives alone and needs assistance for all instrumental activities of daily living (IADLs) and activities of daily living (ADLs). One family member provides some informal help, but the patient relies primarily on personal care services (PCS) for assistance with daily activities. The insurer approved PCS 84 hours per week (12 hours per day). The patient's daughter (as patient designee) requested an increase of PCS to 24 hours per day, live-in services, which was denied. An external appeal was requested.

The most recent Uniform Assessment System (UAS) provided was reviewed. Functional status for IADLs indicated the patient is totally dependent for ordinary housework, meal preparation, shopping; she needs maximal assistance for managing medications and finances, phone use, stairs, transportation. For ADLs, the patient needs maximal assistance for bathing, dressing lower body; extensive assistance for personal hygiene, dressing upper body, transfer toilet, toilet use, walking, locomotion; limited assistance for eating, bed mobility.
The prior UAS was reviewed. The only difference in ADL function between the two assessments was bed mobility; reported as setup help; and limited assistance.

As per NYS (New York State) regulations for personal care services, in order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep in an 8-hour sleep period per day. There are no nighttime activity logs available to help determine the frequency of the patient's nighttime ADL needs. However, the available information supports the patient's need for assistance with daily activities that extend from morning to evening; plus at least some nighttime ADL care (e.g., toileting/ incontinence care, bed mobility). The UAS does not indicate difficulty sleeping or frequent nighttime activity by the patient; and so, it appears her care needs can be met with live-in services. At night, assistance with ADLs (e.g.,toileting/incontinence care) can be provided before and after the aide's 5-hour sleep period.

Recommendation is given to approve an increase in Personal Care Services, 24 hours per day (live-in), 7 days per week, for a total of 91 hours per week.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for personal care services (PCS), 24 hours a day (live-in), 7 days a week, for a total of 91 hours a week services is substantiated.

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