Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease; Dementia
Treatment: for Personal Care Assistance (PCA) services 24 hours per day (split shift), 7 days per week 
The insurer denied coverage for Personal Care Assistance (PCA) services 24 hours per day (split shift), 7 days per week 
The denial is overturned.

The patient is a female with a medical history of Parkinson's disease, coronary arteriosclerosis, severe vascular dementia, cerebral infarction, abdominal aortic aneurysm and osteoarthritis.  The patient has been receiving 84 hours per week of personal care assistance PCA) services.  Per the Medical Request for Home Care, the patient is unable to reposition herself and is at high risk for developing pressure ulcers; the patient requires position changes every 2 hours.  The patient requires assistance with all activities of daily living (ADLs) and requires 24/7 care as her daughter is returning to in-person work.  The patient has full incontinence and contractures, and is bed and wheelchair-bound.  There are unscheduled needs including toileting and repositioning.  Home visit notes, time tasking tools, Uniform Assessment System (UAS) - New York State and case notes are submitted.

As per the New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016:

(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.
***(2) Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.

Based on the review of the medical record and New York Codes Rules and Regulations, the coverage for Personal Care Assistance (PCA) services 24 hours per day (split shift), 7 days per work is considered medically necessary for this patient. The patient needs maximum assistance with bed mobility, transfers and toileting.  Later physician certification in January note high risk of decubiti, the patient's dependence for Activities of Daily Living (ADLs), and need for toileting and position.  The use of pads lessens the problems of incontinence but does not by themselves prevent them when this patient is incontinent. Documentation subsequent to the determination demonstrates the need for unscheduled tasks during the night.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for Personal Care Assistance (PCA) services 24 hours per day (split shift), 7 days per week is substantiated. The insurer's denial should be overturned.