Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary heart disease, dementia, benign prostatic hyperplasia.
Treatment: Personal care services level 2 of 24 hours per day, 7 days per week split shift for a total of 168 hours per week.

The insurer denied coverage for personal care services level 2 of 24 hours per day, 7 days per week split shift for a total of 168 hours per week.  The denial is overturned. 

The patient is of advanced age with a history of anxiety, cancer, coronary heart disease, dementia, benign prostatic hyperplasia, hypertension, generalized muscle weakness, chronic pain, polyosteoarthritis, hypercholesterolemia, abnormality of gait and mobility, urinary incontinence and wandering.  Per the New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, his daughter and personal care aide were present. The patient is Russian speaking and lives in a one-bedroom apartment with his spouse. Their apartment is on the second floor of a building with elevator access. 

He is totally dependent for meal preparation, ordinary housework, managing finances, phone use and shopping. The patient needs maximum assistance with managing medications, stairs, transportation, bathing, dressing his lower body and toilet use. The patient is frequently bladder incontinent and occasionally bowel incontinent, and he uses pull-ups. He needs extensive assistance with personal hygiene, dressing his upper body, toilet transfer, bed mobility, walking and locomotion. The patient uses an assistive device for locomotion. 

He had one reported fall in the last 30 days when he was walking from the kitchen to the living room and hit his face. The patient needs limited assistance with eating. It was noted that the patient has two small pressure ulcers on his right buttock, and his physician was contacted about wound care orders. 

An increase to personal care services level 2 of 24 hours per day, 7 days per week split shift for a total of 168 hours per week is being requested.

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

"(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 has cognitive and physical impairments that render him unable to toilet, change pull-ups, transfer, turning and positioning (T&P) without assistance. The UAS (uniform assessment system) notes no decubiti. Contrary to the assertion in the Final Adverse Determination, page 13 of the UAS notes 2 small pressure sores. 

The provision of diapers and alternate pressure beds is not by itself adequate for prevention of pressure sores. Changing diapers regularly and positioning are also necessary. In this case there are already small ulcers. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The patient needs extensive-maximal assistance with all functions, is incontinent and has pressure sores. There are 24-hour unscheduled personal care needs. His needs are not just supervisory.  

Based on the above, the medical necessity for the requested Personal Care Services Level 2 of 24 hours per day, 7 days per week split shift for a total of 168 hours per week is not substantiated. The insurer's denial is overturned.