Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinsonism, cognitive impairment, recurrent falls, impaired mobility, polyarticular osteoarthritis, peripheral edema, status post hip replacement. 

Treatment: PCS [personal care aide] services of 24 hours per day, 7 days per week live in. 

The insurer denied coverage for PCS services of 24 hours per day, 7 days per week live in. 

The denial is overturned. 

This is the case of a female patient with a past medical history of evidence of parkinsonism, cognitive impairment, recurrent falls, impaired mobility, polyarticular osteoarthritis, peripheral edema, status post hip replacement, status post knee replacement, osteopenia, hypertension, age related cataracts, weight loss and urinary and fecal incontinence. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient was residing at Sub-Acute Rehabilitation (SAR) status post (s/p) right lower extremity (RLE) deep vein thrombosis (DVT). She subsequently fell sustaining a pelvic fracture. She was discharged from Rehab. 

Needs are: 

Total dependence for ordinary housework and managing finances; 
Maximal assistance for meal preparation, managing stairs, shopping, transportation, bathing and dressing her lower body; 
Extensive Assistance for phone use, personal hygiene, dressing her upper body, walking, locomotion- uses assistive devise (AD), toilet transfer and toilet use; 
Limited assistance for managing medications and bed mobility. 

She needs supervision with eating; 
Cognition: There is mild impairment. She has mild memory loss, forgetfulness and confusion in the evening. 
Continence: There is urinary but no bowel incontinence. She uses pull-ups. 

An increase to personal care aide (PCS) services to 24 hours per day, 7 days per week live in is being requested. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 

(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 is female patient with cognitive and physical limitations leading to impairments as noted above (needing assistance with basically all). She has cognitive deficits. She is incontinent before her pelvic fracture, already noted she could not handle a commode or soiled pull-up on her own. Expecting her to transfer and locomote and handle a diaper or a commode left at bedside is not consistent with her assessed functional limitations. The provision of diapers and durable medical equipment (DME) is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers"- changing diapers regularly and positioning are also necessary. 

There is no scheduled informal care. 

In this case, provision for safety is part of the larger need for assistance. Given the above sustained limitations and her unscheduled needs, 24-hour live-in is approved. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's assessment of the patient's needs. 

The insurer's denial of coverage for the requested Personal Care Aide (PCS) Services of 24 hours per day, 7 days per week live in is reversed. Medical necessity is substantiated.