Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary atherosclerosis, hypertension, atrial fibrillation, hypothyroidism, bladder cancer.

Treatment is personal care worker (PCW) service 3 days per week, 12 hours per day; and 4 day per week, 12 hours per day Consumer Directed Personal Assistance Services (CDPAS); 84 hours per week, (split shift with mutual spouse).

The insurer denied coverage for personal care worker (PCW) service 3 days per week, 12 hours per day; and 4 day per week, 12 hours per day Consumer Directed Personal Assistance Services (CDPAS); 84 hours per week, (split shift with mutual spouse).
 
The denial is overturned.

This patient has an extensive medical history associated with functional impairment affecting his ability to perform all daily activities. The patient lives with his wife. He receives some informal care from his children, but he mostly depends on personal care services for assistance with ADLs (activities of daily living) and IADLs (instrumental activities of daily living). The patient and his wife had been receiving personal care services as a mutual case. Each spouse was approved for 84 hours per week, 12 hours per day; and so, daily total was 24 hours of continuous services from two aides, each working a 12-hour shift per day, providing care to the patient and his wife over 24 hours. Services are provided as personal care worker (PCW) services and Consumer Directed Personal Assistance Services (CDPAS). The insurer decided to reduce services to 24 hours per day, live-in as mutual services for the patient and his wife; still provided as PCW services and CDPAS. The patient (via designee) appealed the decision, which was denied. An external appeal was requested.

The most recent UAS (uniform assessment system) provided was reviewed. The functional status report for IADLs indicated the patient was totally dependent for meal preparation, ordinary housework, and shopping; he needed maximal assistance for transportation, managing finances, stairs; extensive assistance for managing medications, and phone use. For ADLs, the patient needed maximal assistance for bathing, dressing lower body, toilet use; extensive assistance for personal hygiene, dressing upper body, transfer toilet; limited assistance for walking, locomotion, bed mobility, eating. 

As per NYS (New York State) 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 to be determined in this review is whether the patient's personal care needs can be adequately met with live-in services or if continuous (split shift) services are necessary.
The patient's need for assistance for toileting/incontinence care and mobility has not changed. A recent detailed description of frequency of care would have been preferable; but based on all other available information, the risk of decreasing essential care (i.e., decreasing hours of ADL care) cannot be medically justified, as sepsis and traumatic falls can be critical events for this patient. 

Recommendation is given to approve Personal Care Worker service 3 days per week, 12 hours per day; and Consumer Directed Personal Assistance Services 4 days per week, 12 hours per day; 84 hours per week (split shift with mutual spouse).  

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 a personal care worker (PCW) service 3 days per week, 12 hours per day; and 4 day per week, 12 hours per day Consumer Directed Personal Assistance Services (CDPAS); 84 hours per week, (split shift with mutual spouse) is overturned. Medical Necessity is substantiated.