Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, gastroesophageal reflux disease, bipolar disorder, occasional bowel incontinence and recurrent urinary tract infections (UTIs).

Treatment: Personal care aide (PCA) services 7 days x 24 hour split shift.

The insurer denied coverage for personal care aide (PCA) services 7 days x 24 hour split shift as not medically necessary.

The denial is overturned.

This female patient has a history of hypertension, gastroesophageal reflux disease, bipolar disorder, occasional bowel incontinence and recurrent urinary tract infections (UTIs) which are exacerbated by incontinence and wet diapers. 

The patient requires full time, 24-hour, split shift assistance to enable her caregivers to change her diapers more frequently, ideally every 2 hours. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; note:

"(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.

(2) Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep....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.

The patient has incontinence and has recurrent urinary tract infections. The implication of live-in care is that she could go 5 or more hours without a diaper change, which is not optimal for managing incontinence. Women with incontinence are at increased risk for recurrent UTIs as noted in the Uptodate article "Approach to the adult with recurrent infections." Optimal management of incontinence is important. 

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

The insurer's denial of coverage for personal care aide (PCA) services 7 days x 24 hour split shift is overturned. Medical necessity is substantiated.