Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Respiratory Failure with hypoxia Insomnia, Osteoarthritis, Gastroesophageal Reflux Disease, and recent Stroke

Treatment: Personal Care Assistance services, 24 hours per day, 7 days per week, live-in

The insurer denied coverage for personal care assistance services, 24 hours per day, 7 days per week, live-in

The denial is overturned.

According to the documentation submitted, this is the case of a female with a history of high blood pressure, chronic kidney disease, squamous cell cancer, asthma, age-related cognitive decline, factor ll deficiency, diastolic dysfunction, zoster, constipation, difficulty walking, functional urinary incontinence, insomnia, osteoarthritis, gastroesophageal reflux disease, recent stroke with hemiplegia and  acute respiratory failure with hypoxia with recent hospitalization.  The patient lives alone.  

The patient was hospitalized twice in recent months due to stroke and respiratory failure resulting in significant functional decline. Prior to these events, the patient already had functional impairment requiring assistance with activities of daily living and independent activities of daily living. She lives alone and has been receiving personal care assistance services 70 hours per week. Informal care includes some assistance from her son with medications and finances. The family requested increase of personal care assistance services to 24 hour live-in, which was denied. 

This patient has chronic medical conditions that caused functional impairment prior to the recent acute medical events, and she was receiving personal care assistance services 10 hours per day. The records provided for review include very limited information of the recent hospitalizations (no hospital records are available other that some discharge instructions and diagnoses); but the physician, nursing and rehab records and the patient's daily care needs described in the activity logs (after second hospitalization) provide a useful source of information to formulate an impression of the patient's current functional status.

The request for increase of personal care assistance services is for 24 hours live-in. As per New York State regulations for personal care aide live-in services, the patient's need for assistance must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep in an 8 hour sleep period per day. If the patient's care needs are too frequent to allow the aide to obtain 5 uninterrupted hours of sleep per day, then continuous services (split shift) are necessary. The activity logs indicate the patient needs assistance with independent activities of daily living and activities of daily living during daytime hours; and at night the patient needs assistance with toileting/incontinence care, repositioning in bed, medication assistance, providing fluids as needed. For 2 of the nights, it was noted the patient slept for 5 and 7 12 hours. Sleep time was not noted for the 3rd night. It appears that during one night, the caregiver repositioned the patient once when the patient was asleep. It is not possible to predict the exact time and frequency of the patient's care needs every night based on information from 3 nighttime activity records; but it appears that live-in services can be an acceptable plan for this patient. There are no behavioral issues reported that disrupt sleep of the patient or caregiver; the patient sleeps for extended periods of time; she does not need to get out of bed, and there is no report that she attempts to get out of bed unassisted. It appears the patient's nighttime care needs can be managed before and after the time the aide sleeps (5 hours); and the patient will benefit from the additional help she can receive during evening and night hours that are not available to her with her current services (personal care assistance 10 hours per day). 

Personal Care Assistance services 24 hours per day, 7 days per week live-in is medical necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for personal care assistance services, 24 hours per day, 7 days per week, live-in is reversed. Medical necessity is substantiated.