Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abnormality of gait and mobility

Treatment: Personal care assistance (PCA) services of 2, 12 hour split shifts per day, 7 days per week (Monday through Sunday) for a total of 168 hours per week

The insurer denied coverage for personal care assistance (PCA) services of 2, 12 hour split shifts per day, 7 days per week (Monday through Sunday) for a total of 168 hours per week

The denial is overturned. 

This female patient has a history of anxiety, bipolar disorder, dementia, depression, delusional disorders, osteoporosis, hypertension, gastroesophageal reflux disease, hyperlipidemia, mixed incontinence, neuralgia, neuritis, insomnia, pain, repeated falls and abnormality of gait and mobility.

The records provided for review support the patient's needs for 24 hour care, which can be provided as live-in services or continuous services (split shift). As per NYS regulations for personal care 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 expect to 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 obtain this amount of sleep on a regular basis, then continuous services are indicated, i.e., split shift. 

Although there were no activity logs detailing the patient's activity throughout the day and night, the UAS [uniform assessment system] and recent information from the appealer and physician provide sufficient information to support split shift services. It is reasonable to conclude that the patient needs a caregiver present and awake to assist with daytime and nighttime care needs including the following: The patient has frequent episodes of incontinence during the day and night which need prompt attention from the aide to prevent skin damage.  The patient should not remain in a soiled diaper for up 5 hours (when live-in aide is asleep). The patient has chronic pain and relies on the aide for pain relief (e.g., assist with medication, reposition in bed). The patient has h/o [history of falls] falls and needs hands-on assistance for stability, and direction/cues for safety with mobility related tasks, which includes the patient's unscheduled nighttime walks around the house. The patient needs a caregiver from morning to evening to prepare and assist with all meals, snacks, fluids to maintain adequate nutrition and hydration. Assistance is needed for all routine ADLs [activities of daily living] including bathing daily and morning and evening ADLs (personal hygiene, dressing). The aide is also responsible for all household related tasks and shopping. The frequency of the patient's daily care needs does not appear compatible with live-in aide services. There does not appear to be a clear window of opportunity for a live-in aide to have 5 uninterrupted hours of sleep per day on a regular basis.

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

The carrier's denial of coverage for personal care assistance (PCA) services of 2, 12 hour split shifts per day, 7 days per week (Monday through Sunday) for a total of 168 hours per week is overturned.  The medical necessity is substantiated.