Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), urinary tract infections (UTIs)

Treatment home health aide services, 2 x 12 hours (split-shift)

The insurer denied coverage for home health aide services, 2 x 12 hours (split-shift).

The denial is overturned.

The patient is female with a medical history of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), urinary tract infections (UTIs), Alzheimer's disease, and falls. Assistance is required for activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Her condition is noted to be declining. Her informal helper does not help with ADLs. An increase in home health aide services from 84 hours a week to 2x12 hours (split-shift) is requested. 

Needs are: 

1. Maximal assistance for dressing lower body, toilet use.
2. Extensive Assistance for hygiene, dressing upper body, walk, locomotion, toileting.
3. Limited assistance for bed mobility;
4. Cognition: There is impairment due to dementia. 
5. Continence: There is occasional urinary incontinence. She uses pull-ups.

Nighttime Needs Log shows she gets up multiple times/night for toileting.

The insurer has denied coverage for home health aide services, 2 x 12 hours (split-shift) as not medically necessary. In their Final Adverse Determination letter, they write that all the patient's needs can be safely met with the current 84 hours a week. There has been no change in her impairments. 

Social worker is appealing. In her detailed Advocacy Report, she writes that 2x12 hours split shift care (168 hours total) is medically necessary due to the patient's multiple chronic conditions including dementia. The plan has not considered the patient's overnight toileting and incontinence care needs.

In a letter, the doctor notes that the patient gets up 4-5 times/night and due to physical and cognitive impairments is at high risk for a fall. She feels the patient needs 24/7 care.

The reviewer disagrees with the plan's assessment.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 

(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.

The patient needs assistance with walking, transfers, and toileting. She uses diapers and can be found with wet ones in the morning. She has cognitive impairment. She gets up multiple times nightly for toileting. If she is able to use the bathroom she needs assistance with transfers, ambulation, and toileting. If she does not, then she is incontinent in bed and unable to tend to her own clean-up. Lack of that could leave her with soiled diapers for many hours. Her needs are not scheduled. 

The requested change is approved. The health care plan did not act reasonably, with sound medical judgement, and in the best interest of the patient.

The insurer's denial of coverage for home health aide services, 2 x 12 hours (split-shift)
 is overturned. Medical necessity is substantiated.