Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, Osteoarthritis, Vision and Hearing impairment, and Impaired balance. 
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (live-in).
The insurer denied coverage for Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (live-in).
The denial is upheld. 

This is a female patient who has substantial functional impairment due to cognitive and physical decline. The patient lives alone. The patient's son has been hiring aides to provide his mother with assistance for daily activities. Physician's office note indicates the patient has 24 hour aide services. The insurer approved personal care services (PCS) 49 hours per week. The son requested PCS 24 hours live-in, which was denied by the insurer. 

Uniform Assessment System (UAS) documentation was provided for review. The UAS functional assessment indicated the patient needs maximal assistance or is totally dependent for all instrumental activities of daily living (IADLs). The patient needs extensive assistance for most activities of daily living (ADLs), except upper body dressing, eating (limited assistance); and personal hygiene (supervision). The patient's medical history includes: dementia, osteoarthritis, vision and hearing impairment, and impaired balance. Considering the patient's medical history and substantial functional impairment, it is medically necessary for the patient to have caregiver assistance 24 hours per day to include routine ADLs and IADLs, and ADLs that occur at various unscheduled times of the day and night. 

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for PCS; this includes direct care from informal caregivers, and from hired aides at the expense of informal caregivers. Considering the son is requesting PCS 24 hours live-in, it is reasonable to conclude that there are no informal caregivers who can provide assistance to the patient on a regular basis through the day and night; and private pay assistance may not be a long term option. 

As per NYS regulations for live-in aide 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 ADLs 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 frequency of the patient's nighttime personal care needs can only be assessed based on the letter provided by one of the patient's longtime aides. She reports that the patient wakes up and attempts to get out of bed to go to the bathroom 6-10 times per night, and if the aide was not there, the patient would most likely fall. This frequency of care appears incompatible with a live-in aide's need for 5 uninterrupted hours of sleep per day. With the need for routine ADLs and IADLs care during the day, plus all unscheduled care needs, it does not appear the aide could have 5 uninterrupted hours of sleep at any other time of the day. The information provided for review indicates the patient's care needs are greater than what can safely be provided by live-in aide services. 

The maximum amount of services that can be recommended from this review is limited by the amount of services requested, as described in the insurer's final adverse determination notice; in this case 24 hour live-in services. The patient's care needs are 24 hour continuous. Live-in cannot be recommended for approval from this appeal. 

The carrier's denial of coverage for Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (live-in) is upheld.  The medical necessity is not substantiated.