Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Rheumatoid arthritis. 
Treatment: Personal Care Worker (PCW) services, 7 days per week, 24 hours per day; continuous care by more than 1 person. 

The insurer denied coverage for Personal Care Worker (PCW) services, 7 days per week, 24 hours per day; continuous care by more than 1 person. 

The denial is overturned. 

This is a female patient with a history of dementia, hypertension, rheumatoid arthritis, functional urinary incontinence, fecal incontinence, insomnia, chronic fatigue, gait abnormality, hearing loss, and vision loss. She is currently approved for personal care worker (PCW) services 42 hours per week. The patient (via designee) requested an increase of PCW services to 7 days per week, 24 hours per day, continuous care (split shift). Uniform Assessment System (UAS) documentation indicates the patient is totally dependent on caregivers for most instrumental activities of daily living (IADLs), except stairs and managing medications (maximal assistance). The patient needs extensive assistance for most activities of daily living (ADLs), except lower body dressing (maximal assistance), and bed mobility and transfer toilet (limited assistance). The patient has substantial functional impairment requiring assistance with all daily activities. Considering her medical history and functional impairment, it is apparent that the patient needs assistance for all daily activities. Therefore, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day and night to provide assistance for all daily activities. The patient needs assistance for daily activities that occur at various scheduled and unscheduled times throughout the day and night. Without adequate assistance, the patient is at risk for significant adverse events, including falls/injuries, malnutrition, dehydration, skin injury. 

The insurer's recommendation to split the 6 PCW hours per day to address morning and late day ADLs is not a practical solution, as the patient will have no assistance for mobility, toileting/incontinence care in the middle of the day; and at least 1 meal per day will still be unattended by the aide. It appears that informal caregivers are staying with the patient for 12 hours per day. The nighttime logs indicate caregivers are with the patient through the night. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. Considering the request for increase of PCW services is for 24 hours continuous split shift, it is reasonable to conclude that the informal caregivers are unable to continue providing care on a regular basis. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that need assistance at various and unscheduled times through the day and night. 

The patient needs assistance with toileting, incontinence care, walking and transfer in and out of bed at various times through the night. As per NYS regulations for personal care 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 high frequency that the aide cannot have this amount of sleep on a regular basis, then continuous services are indicated, i.e. split shift. It does not appear that the patient's care needs can be met by a live-in aide; and so continuous services (i.e. split shift) are indicated. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for PCW services, 7 days per week, 24 hours per day; continuous care by more than 1 person is overturned. The medical necessity is substantiated.