Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary disease, status post (s/p) angioplasty, congestive heart failure (CHF), atrial fibrillation, cerebral vascular accident (CVA) x 3

Treatment: Personal care services

The insurer is denied coverage for personal care services.  The denial is reversed. 

The patient was a male has extensive medical history including cardiovascular and cerebrovascular disease, diabetes mellitus (taking insulin), late stage CKD, vascular dementia, inflammatory arthritis (taking prednisone), dysphagia, sepsis due to UTI or pneumonia, BPH, incontinence, sacral pressure ulcer. The patient has severe functional impairment as a result of the effects of his medical conditions. He lives at home with his wife. She has health problems that restrict her ability to provide care to her husband. The patient is currently receiving personal care services 24 hours, live-in (91 hours per week), which is noted as a mutual case, indicating the wife also qualifies for some services (e.g. household tasks). The wife reports that the patient's condition has become worse. He has frequent nighttime needs, including incontinence care. She reports that she is often awake at night attending to her husband, as the live-in aide is not obligated to work through the night. One of the physician's letters indicated the aide does help at night but it is exhausting and both the wife and aide are unable to sleep. The wife requested increase of personal care service hours to 24 hours, spilt shift. This was denied by the insurer. An external appeal was requested.

As per NYS regulations for personal care services, in order to qualify for 24 hour live-in aide, the patient's care needs must be sufficiently infrequent that the aide can expect to have at least 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 obtain this amount of sleep on a regular basis, then continuous services are indicated, i.e. split shift. 

The patient is bedbound and requires either maximal assistance or total dependence for all IADLs and ADLs. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. Therefore, if the patient's wife is unable to provide her husband with assistance for daily activities on a regular basis, then it is medically necessary for all ADL and IADL care to be provided by personal care aides. No other informal caregivers are available to provide care on a regular basis; son visits weekly and does not usually provide personal care assistance, as per UAS.

The issue is whether the patient needs an aide to provide ADL care through the night hours. Considering the information provided for review, it is apparent the patient has severe functional impairments and depends on caregiver assistance for all daily activities. The patient needs assistance with all ADLs, including incontinence care, which occurs at unscheduled times throughout the day and night; and bed mobility, which is needed for turning and repositioning at regular intervals when the patient is in bed for pressure relief, and at various other times as needed to relieve discomfort that may be due to uncomfortable position in bed. The frequency of these needs does not appear to allow a live-in aide to have at least 5 uninterrupted hours of sleep each night on a regular basis..

Personal Care Services, 24 hours per day, 7 days per week (split shift), total of 168 hours per week are medically necessary.

Based on the above, the medical necessity for the increase to personal care services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week is substantiated.  The insurer's denial is reversed.