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202304-161128

2023

VNSNY CHOICE Health Plans

Managed Long Term Care

Cardiac/ Circulatory Problems, Endocrine/ Metabolic/ Nutritional

Home Health Care

Medical necessity

Overturned

Case Summary

Diagnosis: Congestive heart failure, diabetes and osteoarthritis.
Treatment: Consumer and self-directed personal assistance services 24 hours a day split shift (two 12-hour shifts per day), 7 days a week, a total of 168 hours a week.

The insurer denied coverage for consumer and self-directed personal assistance services 24 hours a day split shift (two 12-hour shifts per day), 7 days a week, a total of 168 hours a week. The denial is overturned.

This is an elderly adult with chronic medical problems including congestive heart failure, diabetes and osteoarthritis who lives alone in a 2-bedroom apartment. The insurer approved consumer and self-directed personal assistance services 56 hours per week and the request is for consumer and self-directed personal assistance services 24 hours a day, 7 days a week (split shift), totaling 168 hours per week.

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as "Minimally impaired." She is totally dependent to maximal assistance for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. She is also totally dependent for much of her functional mobility including locomotion, ambulation and toilet transfer/use. Maximal assistance is needed for bed mobility, as well as bathing and dressing. Extensive assistance is needed for personal hygiene. Limited assistance is needed for eating. She is frequently incontinent of bladder and occasionally incontinent of bowel. There have been no reported falls over the prior 90 days.

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 consumer and self-directed personal assistance services 24 hours a day split shift (two 12-hour shifts per day), 7 days a week, a total of 168 hours a week services is substantiated.

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