Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, hypertension, chronic obstructive pulmonary disease, hypercholesterolemia, cerebral infarction.

Treatment: Personal care services (PCS) of 24 hours per day, 7 days per week (live in or split shift)

The insurer denied coverage for the personal care services of 24 hours per day, 7 days per week (live in or split shift)

The denial is overturned

The patient is a female with a past medical history of diabetes, hypertension, chronic obstructive pulmonary disease, hypercholesterolemia, cerebral infarction, dementia, carotid stenosis, anxiety, depression, chest pains, falls, inguinal hernia of the right side with obstruction, rib fracture, small bowel obstruction, arthritis, obesity, vascular dementia with behavioral disturbance, lumbar radiculitis, unsteady gait and memory loss. The patient is status post cerebral vascular accident. She is in Rehab and is receiving rehabilitation services, such as skilled physical therapy and occupational therapy. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, her daughter and Social Worker were present on the call. Over the last few months, the patient has been experiencing increased weakness and difficulty ambulating with an assistive device. 

Needs are: 

Total dependence for housework, stairs and transportation; Maximal assistance for meals, finances, shopping and lower body (LB) dressing; Extensive Assistance for meds, bathing, upper body (UB) dressing and toilet transfer and use; Limited Assistance for phone use, personal hygiene, bed mobility and walking.
Cognition: There is worsening impairment. 
Continence: There is frequent urinary but no bowel incontinence.

An increase to personal care services of 24 hours per day, 7 days per week (live in or split shift) is being requested.

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.

The patient is incontinent of urine multiple times a day. The insurer has provided pull-ups and has instructed the patient in limiting fluids and staying clean.

The patient has cognitive impairment and needs extensive assistance with Activities of Daily Living such as transfers and walking as well as others that require hand use such as dressing. She cannot be expected to effectively monitor oral intake, change diapers and keep herself clean and dry. These would be important considerations without any sores. Doctor office visit noted buttocks sores. The request for 24-hour coverage is approved. It is for more than just supervision or general safety measures.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's interpretation of the patient's needs.

The insurer's denial of coverage for the requested Personal Care Services (PCS) of 24 hours a day, 7 days a week (live in or split shift), 168 hours total is reversed. Medical necessity is substantiated.