Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia

Treatment: personal care services, Level 2 of 24 hours per day (split shift), 7 days per week for a total of 168 hours per week

The insurer is denied coverage for personal care services, Level 2 of 24 hours per day (split shift), 7 days per week for a total of 168 hours per week

The denial is overturned. 

This male patient has a history of coronary artery disease, hypertension, benign prostatic hyperplasia, dementia, brain cancer, epilepsy, metabolic encephalopathy, diabetes mellitus, asthma, chronic interstitial lung disease, peripheral vascular disease, cerebral vascular accident, abnormalities of gait and mobility, muscle weakness and recurrent urinary tract infections.

As per NYS regulations for personal care services, 24 hour care can be provided as live-in services or continuous (split shift) services. 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 frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services are indicated, i.e., split shift. The issue involved in this review is whether the patient's daily care needs can be adequately met with live-in services; or if continuous services are necessary.
Due to dementia, the patient may not consistently inform the caregiver when incontinence occurs; and so, the caregiver must periodically check the patient for soiled diaper. The Uniform Assessment System (UAS) nurse instructed the caregivers on the importance of skin care and frequent change of diapers in order to prevent skin impairment. It is necessary to maintain good skin hygiene, as prolonged contact of skin with soiled wet diapers increases risk of incontinence associated skin damage (e.g., fungal infection, dermatitis). This is a source of discomfort for the patient, and can result in further complications (e.g., secondary skin infection). Incontinence is also associated with increased risk of pressure ulcers. 
Fecal incontinence can increase risk of urinary tract infection (UTI). The patient has diabetes mellitus, which is associated with increased risk of UTI and increased risk of complicated UTI (e.g., sepsis). Prompt incontinence care is necessary to help prevent UTI per physician's letter, patient has history of (h/o) recurrent UTI.
Based on information provided for review, the patient's need for activities of daily living(ADL) care that occurs at unscheduled and recurring times throughout the day and night (incontinence care, repositioning) is not compatible with the hours of service provided by a live-in aide (i.e., aide is unavailable to provide care during 5 uninterrupted hours of sleep each day). Therefore, personal care aide (PCA) continuous services (split shift) is medically necessary in order to properly and safely meet the patient's care needs throughout the day and night.
Personal Care Services level 2, 24 hours per day (split shift), 7 days per week, total 168 hours per week are medically necessary.

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

The carrier's denial of coverage for the personal care services, Level 2 of 24 hours per day (split shift), 7 days per week for a total of 168 hours per week is overturned.  The medical necessity is substantiated.