Appeal type: Medical necessity
Decision: Overturned

 Diagnosis: Chronic pain, Cardiopulmonary disease, Obesity, Vision loss

Treatment: Personal Care Worker (PCW) services 24 hours per day, continuous care by more than one person (split-shift)

The insurer denied coverage for PCW services 24 hours per day, continuous care by more than one person (split-shift).

The denial is overturned. 

This is a female patient who has an extensive medical history and functional impairment, requiring assistance with most daily activities. The patient was previously approved for personal care worker (PCW) services 48 hours per week. The patient requested an increase of PCW services to 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week. The patient was discharged home from acute rehabilitation. It is not known whether the patient has been receiving any other type of personal care assistance since her return home, in addition to PCW services 56 hours per week.

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple chronic medical conditions. Accelerated periods of decline can occur in response to new/acute medical events. As people age, functional reserve decreases; and so when a new medical problem results in further functional decline, it becomes increasingly difficult to return to the prior level of function. Rehabilitation can help, but there may be limits to improvement due to the nature of the underlying medical conditions. This patient has several chronic medical conditions that most likely affect her ability to perform daily activities. The patient's medical history can provide some basis for understanding her functional impairment and this includes: chronic pain, cardiopulmonary disease, obesity, and vision loss. Recent acute medical events resulted in further functional impairment. Some improvement was noted from acute rehabilitation, but based on the physician's letter it appears the patient was having increased difficulty with daily activities after she returned home from in-patient rehabilitation.

Considering the patient's medical history and functional impairment, it is apparent that the patient needs assistance for most daily activities, including activities of daily living (ADLs) that occur at various times throughout the day and night. Therefore, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day and night to provide assistance for all daily activities. As per New York State (NYS) regulations for personal care services, 24 hour care can be provided as live-in or continuous services. In order to qualify for 24 hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8 hour sleep period each day. If the patient's care needs are of such high frequency that the aide cannot have this amount of sleep on a regular basis, then continuous services are indicated (i.e. split shift). There are no available records describing the specific frequency of the patient's nighttime care needs; but the information provided for review supports medical necessity for personal care services for the patient during day and nighttime hours. Based on the physician's letter describing the patient's declining functional status, plus basic practice standards for incontinence care and pressure ulcer prevention, it appears that the patient's need for toileting, incontinence care and repositioning in bed through the night would be too frequent for an aide to consistently have 5 uninterrupted hours of sleep per day. 

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

The medical necessity for PCW services 24 hours per day, continuous care by more than one person (split-shift) is substantiated. The insurer's denial is overturned.