Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, osteoporosis, anxiety, depression, insomnia

Treatment: personal care services (PCS), 24 hours per day, 7 days per week, split shift (two 12-hour shift)

The insurer denied coverage for personal care services, 24 hours per day, 7 days per week, split shift (two 12-hour shift).

The denial is overturned. 

The patient is an elderly female with a history inclusive of Parkinson's disease, osteoporosis, anxiety, depression, insomnia, generalized arthritis, urinary tract infection and history of falls. The telephonic Uniform Assessment System (UAS) - New York Comprehensive Community Health Assessment Report notes that the patient lives alone. The daughter is unable to continue to provide care/assistance on a daily basis. The patient currently receives personal care services 7 hours a day 7 days a week. Her condition is reported to have declined, including worsening cognitive function. She requires assistance with activities of daily living (ADL) and instrumental activities of daily living (IADL), is frequently incontinent of bladder, and requires extensive assistance with bed mobility, walking, locomotion, transfers and toilet use. She has cognitive impairment.

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.

The patient has functional and cognitive impairments. She was assessed 6 months ago and has apparently worsened. Provision of personal care services in this case goes beyond stand-alone supervision/safety. Her cognitive problems do contribute to her being unsafe with doing ADLs. But she also has physical limitations. She has been provided with DME (durable medical equipment) including for incontinence but her use of them is hampered by her impairments manifesting in problems with dressing, toilet use, transfers, and bed mobility. The provision of diapers is not by itself adequate for prevention of pressure sores, changing diapers regularly and positioning are also necessary. 

In view of her need for assistance across a range of functions and superimposed cognitive dysfunction the health plan did not act reasonably in the best interest of the patient. Personal care services, 24 hours per day, 7 days per week, split shift (two 12-hour shift) is medically necessary. 

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 services, 24 hours per day, 7 days per week, split shift (two 12-hour shift) is overturned. Medical necessity is substantiated.