Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar spinal stenosis, Chronic obstructive pulmonary disease (COPD) and Asthma. 
Treatment: Personal Care Services (PCS) for a total of 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week. 

The insurer denied coverage for PCS for a total of 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week.  The denial is overturned. 

This is a female patient who has an extensive medical history associated with functional impairment. She lives alone. As per the insurer's final denial letter, the patient was approved for Personal Care Services (PCS) 42 hours per week, 6 hours per day. The physician's letter indicates the patient is receiving home aide services 8 hours per day; it is not known if the physician had incorrect information, or if the patient was approved for 2 additional hours per day since the insurer's final denial letter. In the Uniform Assessment System (UAS) report and physician's letter it was noted that the patient's daughters provide assistance when the aide is not there. Physician's note indicated family may hire aide privately (available records do not comment on whether this occurred). There are multiple days of nighttime activity logs submitted. It is not clear whether these are completed by the daughters or privately hired aides. The patient requested increase of PCS to 24 hours per day split shift.  

UAS documentation was provided for review. The patient's functional status report indicates the patient needs maximal assistance for most instrumental activities of daily living (IADLs), except managing medications (extensive assistance) and phone use (limited assistance). For activities of daily living (ADLs), the patient needs extensive assistance with most ADLs, except bed mobility (limited assistance) and eating (independent setup help). Based on the available records, it appears the patient has several medical problems which can contribute to functional impairment with daily activities. The UAS diagnosis list includes lumbar spinal stenosis. The UAS also indicates diagnoses of chronic obstructive pulmonary disease (COPD) and asthma. Considering the patient's medical history, symptoms, and functional status, it is medically necessary for the patient to have assistance with IADLs and ADLs that occur at various scheduled and unscheduled times throughout the day and night. Without adequate caregiver support through the day and night, the patient is at risk for adverse medical and safety events. 

As per New York State (NYS) regulations for PCS, 24-hour care can be provided as live-in services, or 24 hour continuous care, i.e. split shift.  In order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 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 have this amount of sleep on a regular basis, then continuous (split shift) services are indicated. Based on the information provided for review, the patient's need for assistance with daily activities during the day and at night (including nighttime ADLs) is too frequent for a live-in aide to have 5 uninterrupted hours of sleep each day on a regular basis. Therefore, continuous services (split shift) are necessary.

As per NYS regulations for PCS, assistance from informal caregivers is voluntary, either from care directly provided by informal caregivers, or from privately hired aides at the expense of informal caregivers. 

The health plan did not act reasonably with sound medical judgment.

The carrier's denial of coverage for PCS for a total of 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week is overturned. The medical necessity is substantiated.