Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease; Dementia.

Treatment: Consumer and Self-Directed Personal Assistance Services of 24 hours per day, 7 days (split shift) for a total of 168 hours per week.

The insurer denied coverage for Consumer and Self-Directed Personal Assistance Services of 24 hours per day, 7 days (split shift) for a total of 168 hours per week

The denial is overturned. 

This female patient has a history of heart disease, dementia, cardiac pacemaker, insomnia, falling and weakness. Per the New York State Department of Health's Uniform Assessment System, the patient lives alone in a private home, but her son lives nearby.  The patient frequently attempts to get up on her own without purpose. She falls because she cannot ambulate independently. 

Needs include: Total dependence for meal preparation, ordinary housework, managing finances, managing medications, stairs, shopping and transportation; Maximal assistance for phone use, bathing, personal hygiene and dressing her upper and lower body; Extensive Assistance for walking, locomotion, bed mobility, eating, toilet transfer and toilet use. She cannot direct her own affairs and wanders at night. She has frequent urinary and occasional bowel incontinence.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 note: "(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. (2) Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep...4) Live-in 24-hour personal care services means the provision of care by one personal care aide for a patient who, because of the patient's medical condition, needs assistance during a calendar day with toileting, walking, transferring, turning and positioning, or feeding and whose need for assistance is sufficiently infrequent that a live-in 24-hour personal care aide would be likely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.

If she does try to use the bathroom she needs assistance in transfers, ambulation and toilet use.  She needs help with bed mobility.  She does have pull-ups but given the frequency of incontinence it would not be advisable for her to lie all night in soiled pull-ups, especially given her impaired mobility and cognition.  The need for increased coverage for unscheduled needs is established.

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

The insurer's denial of coverage for Consumer and Self-Directed Personal Assistance Services of 24 hours per day, 7 days (split shift) for a total of 168 hours per week is overturned.  Medical necessity is substantiated.