Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid arthritis; functional disability

Treatment: Personal Care Services, 24 hours a day, 7 days a week (live in) for a total of 91 hours a week

The insurer denied coverage for Personal Care Services, 24 hours a day, 7 days a week (live in) for a total of 91 hours a week. The denial is upheld. 

This patient is a female with extensive medical history and functional disability is currently hospitalized. She was treated for pneumonia and AKI. Acute problems are resolved. Medical progress notes from last few days indicate the patient is medically stable for discharge waiting for discharge plan to be finalized, including home care services. Physical therapist recommended transfer to sub-acute rehabilitation, but patient declined; prefers going home with home care services. Based on information in the available records, the patient has extensive functional impairment.

Rheumatoid arthritis appears to be the primary cause of her disability. Details of the patient's medical history are limited and there may be other factors contributing to her functional impairment. Even though the Uniform Assessment System (UAS) report is not available, the appeal letter from the physician, hospital records and the insurer's final determination letter provide sufficient information to understand the patient's need for assistance with daily activities. Of greatest concern is her limited ability for any type of self-help when she is at home alone (i.e. impaired bed mobility for repositioning and sitting up in bed; dependence on caregiver for toileting/incontinence care; poor manual dexterity for taking fluids/medications). Based on her functional limitations and the risk for adverse health and safety events, it is medically necessary for the patient to have a caregiver present to assist with ADLs, including the patient's activities that require assistance throughout the day and night (i.e. bed mobility, toileting/incontinence care).

The appeal application indicates the patient's family member (who lives out of state) is the designated representative for the patient. No other informal caregivers are identified in the records provided for review.  In the absence of informal caregivers who can provide the necessary assistance with daily activities, then personal care services are indicated to provide assistance to the patient for activities that are needed throughout the day and night including toileting/incontinence care, bed mobility (turning and repositioning) and assistance when needed for fluids and medications (e.g. pain management, hydration).

This review is for request for PCS, 24 hours per day, 7 days per week (live-in). As per NYS regulations for live-in personal care aides, a person's care needs must be of such frequency that an aide can expect to have at least 5 uninterrupted hours of sleep per day. The patient has pressure ulcers (as per hospital records) and is at high risk for new pressure ulcers. The patient's physician will need to provide directions for frequency of turning and repositioning for pressure relief. It is reasonable to consider it will be more frequent than every 5 hours. In addition, the patient may need repositioning for pain relief or assistance with taking fluids or prn medication at night (e.g. for pain).  The patient needs assistance for toileting/incontinence care. Frequency of the patient's nighttime toileting/incontinence care needs is not known. 

The request for Personal Care Services, 24 hours per day, 7 days per week (live-in), 91 hours per week is denied. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

Based on the above, the medical necessity for Personal Care Services, 24 hours a day, 7 days a week (live in) for a total of 91 hours a week is not substantiated.  The insurer's denial is upheld.