Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia with hallucinations, morbid obesity, insomnia, severe arthritis, neuropathy.
Treatment: Personal care services, Level 2 of 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

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

This elderly patient has extensive medical history associated with functional impairment and decreased ability to perform daily activities. The patient lives alone. She receives assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) from personal care services (PCS) 49 hours per week, 7 hours per day; and private pay aide providing services as 24 hours live-in. 

The patient needs extensive assistance with toileting related tasks. Considering her difficulty with mobility (back and lower extremity pain, right sided weakness, impaired balance, unsteady gait), the first obstacle is getting to the toilet or commode. Notes in the aide care log indicate the aide helps the patient in and out of bed (transfer); and helps lift and move the patient's legs. The patient needs assistance with transfer to commode; and with walking (or wheelchair) to reach the bathroom.  Then she needs weight-bearing assistance to transfer on/off the toilet/commode. The patient also needs extensive assistance with toilet use. Her ability for cleaning/hygiene may be impaired at least partly due to pain in her shoulder (arthritis) and right upper extremity weakness due to stroke. She probably also needs assistance with clothing adjustment (she needs extensive assistance with lower body dressing, and UAS (uniform assessment system) reports patient has difficulty bending). 

Considering the patient's medical history and functional impairment, it is medically necessary, and in the patient's best interest to have a caregiver present and available to provide assistance for all ADLs and IADLs, including ADLs that occur throughout the day and night. The patient's daughter assists with some IADLs when she visits (her address indicates an out of state location). Otherwise, the services provided during non-PCS hours are provided by the privately hired aide (24 hours per day live-in). Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services (including direct care from an informal caregiver or paid services at the expense of an informal caregiver). Considering the request for increase of PCS is for 24 hours split shift, it is reasonable to conclude that 1) there are no informal caregivers who can provide the patient with extended periods of care on a regular basis; and 
2) the family cannot continue private pay services on a long-term basis. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance for daily activities, when necessary, throughout the day and night. Based on the information provided for review, the patient needs assistance for all daily activities; including those that occur at unscheduled times during the day and night. It does not appear her care needs can be adequately met within the service hours provided by a live-in aide. Therefore, continuous personal care services (split shift) are indicated.

Recommendation is given to approve Personal Care Services level 2, 24 hours per day, 7 days per week, (split shift), total 168 hours per week.
 
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, Level 2 of 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week is overturned. Medical Necessity is substantiated.