Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neuromuscular disorder.
Treatment: Home Care / Personal Care HHC [home health care] - Personal Care Aide live in services, 24 hours per day (split shift).

The insurer denied coverage for Home Care / Personal Care HHC - Personal Care Aide live in services, 24 hours per day (split shift).  The denial is overturned. 

This is a female patient who has an extensive medical history including neuromuscular disorder, which resulted in severe functional impairment and chronic respiratory failure.  The patient lives alone and receives live-in personal care aide (PCA) services.  The patient (via designee) has requested increase of PCA services to 24 hours per day, split shift.

Uniform Assessment System (UAS) documentation was provided for review.  The functional status report indicates the patient is totally dependent or needs maximal assistance for most instrumental activities of daily living (IADLs), except managing medications and phone use (extensive assistance).  For activities of daily living (ADLs), it was noted that the patient did not walk, or transfer to a toilet/commode for the entire period.  She is totally dependent for locomotion (wheelchair), and needs maximal assistance for most other ADLs, except eating (extensive assistance). The patient has several medical conditions causing symptoms and functional limitations, but it appears the primary cause of the patient's severe loss of mobility is due to neuromuscular disorder. 

Considering the patient's medical conditions and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present 24 hours per day to provide assistance for all daily activities.  The issue is whether the patient's care needs can be met with live-in services, or if continuous (split shift) services are necessary.  There are no nighttime activity records available.  However, the information provided for review gives a reasonable impression of the patient's care needs throughout the day and night.  The patient needs assistance with the following: all routine ADLs and IADLs at various times from morning through evening; repositioning in bed and chair/wheelchair throughout the day and night for pressure relief (noted in the UAS as every 2 hours); repositioning when needed for pain relief or to help improve breathing; ADLs that occur at various and unscheduled times throughout the day and night (toileting/incontinence care; frequent incontinence); assistance when needed to help secure respiratory apparatus in place through the day and night; assistance with as needed medication for increased dyspnea or pain.

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services.  Considering the request is for PCA services 24 hours per day split shift, it is reasonable to conclude there are no informal caregivers who can provide care for extended periods of time each day or night.  Therefore, personal care services are indicated to provide assistance with the patient's ADL and IADL care needs when needed throughout the day and night.

Considering the amount and frequency of care the patient needs for all IADLs and ADLs as reported in the available records, it does not appear that a live-in aide can meet all the patient's daily care needs as described, and have time for 5 uninterrupted hours of sleep per day on a regular basis.  Therefore, it is medically necessary to provide PCA services 24 hours per day continuous care (split shift). 

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

The insurer's denial of coverage for the requested Home Care / Personal Care HHC [home health care] - Personal Care Aide live in services, 24 hours per day (split shift) is overturned. Medical necessity is substantiated.