Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Severe osteoarthritis
Treatment: Level 2 Personal Care Services, per 15 minutes increase to 24 Hour(s) per Day (Split Shift)

The insurer denied coverage for Level 2 Personal Care Services, per 15 minutes increase to 24 Hour(s) per Day (Split Shift).
The denial is overturned.

This is a female patient with a medical history of severe multiple joint degenerative arthritis, atherosclerotic coronary artery disease, dementia with behavioral disturbances, major depressive disorder, falls with multiple fractures, ataxia, dizziness, spondylosis with myelopathy, peripheral vascular disease, anemia, peripheral neuropathy, chronic kidney disease, recurrent urinary tract infections, pressure ulcer, eczema, left foot injury, abscess, colitis with gastroenteritis, hemorrhoids with bleeding, right eye blindness, and left eye glaucoma. It was noted in the Uniform Assessment System (UAS) - New York comprehensive Community Health Assessment report that the patient lives alone and is currently receiving 69 hours/week of personal care assistance. She is often confused. Maximal assistance is required for bathing, dressing, walking/locomotion, transfer toilet and toilet use. Extensive assistance is required for personal hygiene. Limited assistance is required for bed mobility and eating. Frequent bladder incontinence and occasional bowel incontinence are noted. There were recent falls reported. The first fall resulted in a rotator cuff tear and the second fall resulted in a right wrist fracture. Redness was noted on the sacrum. 

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.

***(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.

The patient has cognitive and visual problems, severe osteoarthritis with pain, incontinence, and fractures due to attempts at unassisted standing. She has early signs of skin pressure changes in the sacrum. She has deteriorated over the last few months. She needs assistance with standing, moving in bed, toileting. She is incontinent multiple times/night and cannot take care of her resultant needs without assistance. The patient will need services multiple times/night; 5 hours of uninterrupted sleep cannot be achieved. Split Shift is approved. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.  

The medical necessity for Level 2 Personal Care Services, per 15 minutes increase to 24 Hour(s) per Day (Split Shift) is substantiated. The insurer's denial is overturned.