Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legally blind, Wheelchair bound
Treatment: 24 hours per day, 7 days per week (Split Shift), total 168 hours per week Personal Care Services, level 2.
The insurer denied 24 hours per day, 7 days per week (Split Shift), total 168 hours per week Personal Care Services, level 2.
The determination is overturned.

The patient is a female with a past medical history of hypertension, hyperlipidemia, carotid artery disease, congestive heart failure, spinal stenosis, obesity, wheelchair dependence, oxygen dependence, legally blind, atrial fibrillation, chronic anticoagulation, iron deficiency anemia, osteoarthritis, urinary incontinence, and diabetes mellitus type 2 with neuropathy who had been assigned personal care assistant (PCA) services 10 hours/day, 7 days/week to total 70 hours/week based on a video assessment.
Notes from the assessment noted the patient was in a Skilled Nursing Facility (SNF) as she had been hospitalized and subsequently transferred to the SNF. The patient's primary care physician (PCP) provided a letter  requesting an increase in home care hours and services to include 2 home health aides, 24 hours/day, 7 days/week. The letter also stated the patient was legally blind and the patient's current hours were not enough as the patient needs someone with her all the time for safety and assistance with all activities of daily living (ADLs). 
The patient underwent an in person assessment. Notes from the assessment stated the patient recently had two falls. In addition, notes from the assessment state the patient lives alone in a studio apartment and has no informal support.
The insurer sent a final adverse determination denial notice continuing to deny the request to increase PCA services stating personal care services are not authorized if the need for assistance can be safely met by using medical supplies and they are not allowed by New York State regulations to provide an aide for safety and supervision alone. The patient's healthcare advocate noted the patient was totally blind and wheelchair-bound and required assistance transferring from her bedside to her commode at night and without assistance overnight, she has already had falls attempting to use the commode by herself. In addition, the advocate noted the patient was on continuous oxygen and required assistance in adjusting her equipment and because she was unable to see and unable to read the airflow levels.  At issue is the medical necessity of 24 hours per day, 7 days per week (Split Shift), total 168 hours per week Personal Care Services, level 2.

The services are medically necessary. The patient's medical provider documented the medical necessity of increased PCA services. The patient's health care advocate further documented because of the patient's blindness she is not able to safely move/transport or adjust her oxygen. Due to her overnight ADL care needs (equipment management) with the potential for loss of oxygen, which would be life threatening, a PCA would not be able to obtain at least 5 hours of sleep. The patient also lives in a studio apartment which would not allow a PCA a place to sleep at least 5 hours overnight and therefore, split shift services are medically necessary. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies.