Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amyotrophic lateral sclerosis.

Treatment: Personal care services, 24 hours a day, 7 days a week (live-in) for a total of 91 hours per week. 

The insurer denied coverage for personal care services, 24 hours a day, 7 days a week (live-in) for a total of 91 hours per week.

The denial is overturned. 

This is a male patient with amyotrophic lateral sclerosis (ALS). He is non-ambulatory, wheelchair bound and wheeled by others. His left arm is paralyzed and he has very limited use of the right. He is totally dependent on ordinary housework, bathing, personal hygiene, dressing his upper and lower body, locomotion, toilet transfer, toilet use, bed mobility and transportation. He needs maximum assistance with meal preparation and shopping. He needs extensive assistance with managing medications, phone use and eating. An increase to personal care services, 24 hours a day, 7 days a week (live-in) for a total of 91 hours per week is being requested.
	
New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 

(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.
...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.

...ii) Level II shall include the performance of nutritional and environmental support functions specified in clause (i)(a) of this paragraph and personal care functions.
(a) Personal care functions include assistance with the following: (1) bathing of the patient in the bed, the tub or in the shower; (2) dressing; (3) grooming, including care of hair, shaving and ordinary care of nails, teeth and mouth; (4) toileting; this may include assisting the patient on and off the bedpan, commode or toilet; (5) walking, beyond that provided by durable medical equipment, within the home and outside the home; (6) transferring from bed to chair or wheelchair; (7) turning and positioning; (8) preparing of meals in accordance with modified diets, including low sugar, low fat, low salt and low residue diets; (9) feeding...

The patient is incontinent of bowel and bladder. Being totally dependent for bed mobility, toileting and transfers he cannot use a urinal by himself, nor can he clean himself or turn or position himself. He cannot manage his respiratory aids, which he is using more frequently. He cannot access food/drink. He has unscheduled needs 24 hours a day.  

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The plan did not adequately take into account the 24-hour needs of the patient. 
							
Based on the above, the medical necessity for the requested personal care services, 24 hours a day, 7 days a week (live-in) for a total of 91 hours per week is substantiated. The insurer's denial is overturned.