Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, Osteoarthritis, Asthma, and Chronic obstructive pulmonary disease. 
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift). 

The insurer denied coverage for Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift). 

The denial is overturned. 

This is a male patient who requires a high level of care for all daily activities due to functional decline from chronic medical conditions. Uniform Assessment System (UAS) documentation indicates he lives alone. He receives personal care services 84 hours per week. The UAS indicates he is receiving personal care services as Consumer Directed Personal Assistance Services (CDPAS). It appears the daughter-in-law is the CDPAS aide. The UAS indicates the patient's son and daughter-in-law take turns to stay with the patient during the CDPAS off service hours. A request was made for an increase of personal care services to 24 hours per day, split shift, which was denied by the insurer. 

The patient's functional status report indicates the patient is totally dependent for all instrumental activities of daily living (IADLs). The patient needs maximal assistance or is totally dependent for all activities of daily living (ADLs). It was noted that he no longer walks, and is not transferred to the toilet (total incontinence). This is a significant change from the previous UAS report. At that time, he was able to at least partly participate in ADLs; he could eat with supervision; he was still able to walk short distances (with weight-bearing assistance). He had episodes of incontinence but was still able to use the toilet. Currently, his out of bed mobility is wheelchair, and he depends on others to propel the wheelchair. The UAS includes the diagnosis of Alzheimer's disease. There is no formal evaluation of cognition with the available records, but based on the UAS report, it appears the patient has severe cognitive impairment. As per the UAS report, the patient also has osteoarthritis, and a history of asthma and chronic obstructive pulmonary disease (COPD). 

As per New York State (NYS) regulations for personal care services, 24 hour care can be provided as live-in services or 24 hour continuous care, i.e. split shift.  In order to qualify for 24 hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can 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 have this amount of sleep on a regular basis, then continuous services are indicated. Based on the information provided for review, the patient's care needs during the day and at night are too frequent to ensure that a live-in aide would have 5 uninterrupted hours of sleep each day on a regular basis. Therefore, continuous services (split shift) are necessary. 

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. Considering the family is requesting personal care services 24 hours per day split shift, it is reasonable to conclude that there are no informal caregivers who can continue to provide care for extended periods of time each day. Therefore, personal care services are indicated to provide assistance with the patient's ADL and IADL care needs when needed throughout the day and night. 

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

The carrier's denial of coverage for the Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is overturned. The medical necessity is substantiated.