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202305-162719

2023

VNSNY CHOICE Health Plans

Managed Long Term Care

Central Nervous System/ Neuromuscular Disorder, Cardiac/ Circulatory Problems, Vision

Home Health Care

Medical necessity

Overturned

Case Summary

Diagnosis: Dementia, legally blind, arthritis, asthma, cardiomyopathy, hypertension, and macular degeneration
Treatment: Increase in Personal Care Services (PCS) to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week
The insurer denied the increase in PCS to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week.
The denial is overturned.

The patient is an elderly female. Her conditions include dementia, legally blind, arthritis, asthma, cardiomyopathy, hypertension, and macular degeneration. Denial of an increase in personal care services (PCS) to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week is being appealed. The plan approved PCS 5 hours/day, 7 days/week, for a total of 35 hours/week.

Uniform Assessment System (UAS) evaluation performed last month shows moderately impaired cognition and functional status total dependence with housework; maximal assistance with meal preparation, managing finances, and shopping; extensive assistance in managing medications, phone use, bathing, lower body dressing, locomotion, walking, and toileting; limited assistance with phone use and upper body dressing; and supervision with bed mobility and eating. The patient has occasional bladder incontinence. Compared to functional status 4 months ago, it shows a decline in functional status with bathing, toileting, and lower body dressing.

A letter from provider notes this patient has more significant cognitive decline and loss of independent function. The patient lives alone. She has gait imbalance and is at high risk of falling. She has incontinence and requires constant attention for skin integrity. She has increasing needs for assistance with ADLs (activities of daily living). The letter recommends 24 hours, split shift care. Medical records have been provided supporting the patient's chronic conditions.

The requested increase in PCS to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with ADLs, health maintenance activities, and routine support services. Denial of an increase in PCS to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week is being appealed. The plan approved PCS 5 hours/day, 7 days/week, for a total of 35 hours/week.

This patient has multiple chronic conditions. UAS evaluation performed last month shows the patient requires assistance with all ADLs, except bed mobility and eating. She is incontinent of bladder. Compared to UAS evaluation completed 4 months ago, there is a decline in functional status with bathing, toileting, and lower body dressing. An appeal statement from the provider notes the patient has more significant cognitive decline, bladder incontinence, loss of independent function, and increasing needs for assistance with ADLs. The approved PCS of 35 hours/week is insufficient to meet the patient's needs for assistance with ADLs. The requested increase in PCS to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week is medically necessary.

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