Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's disease, dementia.
Treatment:  Personal Care Worker (PCW) Services: two 12 hours split shifts seven days per week.

The insurer denied the Personal Care Worker (PCW) Services: two 12 hours split shifts seven days per week.  The denial is overturned.

This patient is an elderly male, who has conditions including Parkinson's disease, dementia, hypertension, tremors, monoplegia, and dysphagia.  He is appealing denial of personal care worker (PCW) services: two 12 hours split shifts seven days per week.  The health plan approved personal care worker (PCW) live-in services, seven days per week.  Uniform Assessment System (UAS) evaluation performed earlier this year shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing medications, stairs, shopping, bathing, lower body dressing, and toilet use; maximal assistance with managing finances, personal hygiene, upper body dressing, and bed mobility; and extensive assistance with eating.  The patient has bowel and bladder incontinence.  Compared to Uniform Assessment System (UAS) evaluation completed three moths previous to the most recent assessment, there has been a decline in managing medications, walking, locomotion, toilet use, and bed mobility.  

An appeal statement from New York Legal Assistance Group (NYLAG) notes the patient has several chronic medical conditions and is homebound and wheelchair bound.  An increase in personal care worker (PCW) services was requested due to functional decline.  A letter from the Provider notes the patient has pressure ulcers due to limited bed mobility and needs to be turned/repositioned every two to three hours.  In addition, the patient needs frequent assistance with toileting overnight.  There are logs provided showing that the patient receives assistance every one to two hours overnight.

The proposed treatment is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.

This patient has multiple chronic conditions.  He is homebound and wheelchair bound.  He is appealing denial of personal care worker (PCW) services: two 12 hours split shifts seven days per week.  The health plan approved personal care worker (PCW) live-in services, seven days per week.  Uniform Assessment System (UAS) evaluation performed on earlier this year shows the patient requires maximal assistance to total dependence with all activities of daily living (ADLs), except extensive assistance with eating.  He is incontinent of bowel and bladder.  Compared to Uniform Assessment System (UAS) evaluation completed three months prior to the most recent assessment, there has been a decline in managing medications, walking, locomotion, toilet use, and bed mobility.  The appeal statements support the patient is dependent with all activities of daily living (ADLs) and requires frequent assistance with toileting, transfers, and turning/repositioning.  The patient's provider has indicated that the patient has pressure ulcers and needs turning/repositioning every two to three hours.  This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift.  The approved personal care worker (PCW) live-in, seven days per week is insufficient to meet the patient's needs.  The proposed personal care worker (PCW) services, two 12 hours split shifts seven days per week is medically necessary.