Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chronic pain, Osteoarthritis, End stage renal disease, Heart failure.
Treatment: 7days/week, two 12 hours, split shift, Personal Care Worker services.
The insurer denied coverage for 7days/week, two 12 hours, split shift, Personal Care Worker services.

The denial is modified.

This is a female patient with a history of end stage renal disease (on hemodialysis), diabetes mellitus type 2, congestive heart failure, osteoporosis, osteoarthritis, hypertension, pain, generalized weakness, urinary tract infection with delirium, chronic anemia and major depressive disorder. The patient lives with her son who is the primary informal caregiver. The patient had been receiving personal care services (PCS) for part of the day and evening, until patient (via designee) requested increase of PCS to 24 hours continuous services split shift. The insurer denied this increase, but approved PCS 24 hours live-in. 

This patient has an extensive medical history and severe functional impairment and requires caregiver assistance for all daily activities. The Uniform Assessment System (UAS) functional status report indicated the patient was totally dependent on caregivers for most instrumental activities of daily living (IADLs), except for a few noted as maximal assistance (medications, transportation, phone use). For activities of daily living (ADLs), it was noted that the patient does not walk; she uses wheelchair for locomotion in her home (total dependence on others to move her in wheelchair). She is totally dependent for lower body dressing and toilet use (which includes incontinence care). All other ADLs need maximal or extensive assistance. As per the UAS, her decision making capacity is minimally impaired with poor/unsafe decisions in certain situations. She has short term memory impairment. Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple medical conditions, and non-medical factors. The patient has multiple medical conditions and associated symptoms that most likely contribute to physical impairment and have a substantial effect on her daily function including: chronic pain, osteoarthritis, end stage renal disease on dialysis, and heart failure. 

Considering the patient's medical history and functional decline, it is medically necessary for her to have a caregiver present throughout the day and night to assist with all daily activities, including scheduled activities, unscheduled activities, and periodic repositioning for pressure relief. It appears the patient's care needs do not meet criteria for live-in services; and therefore continuous (split shift) services are necessary. Assistance from informal caregivers is voluntary as per New York State regulations for PCS. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance to the patient for all necessary daily activities. 

The patient attends dialysis 3 days per week. There is no information as to whether the personal care aide accompanies the patient to dialysis. The patient receives assistance at the dialysis facility as needed. This appears to indicate the patient is assisted by staff at the dialysis center if needed. Without information to support the need for PCS at dialysis, then dialysis hours do not need to be included in the total personal care assistance hours per week. The patient is away from her home for 4.5 hours on dialysis days (3 days per week), which includes time at the dialysis facility and transportation.  Therefore, the request for PCS 168 hours per week is reduced by 13.5 hours to 154.5 hours per week. 

PCS 7 days per week, continuous care by more than one person; 154.5 hours per week is medically necessary. 

The carrier's denial of coverage for 7days/week, two 12 hours, split shift, Personal Care Worker services is modified..