Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, Polyneuropathy and lumbar spinal stenosis/ radiculopathy

Treatment: Personal Care Services (PCS), 24 hours a day, 7 days per week (live-in), for a total of 91 hours

The insurer denied coverage for Personal Care Services (PCS), 24 hours a day, 7 days per week (live-in), for a total of 91 hours.

The denial is overturned. 

This is a female patient who lives alone and needs substantial assistance for mobility and daily activities. She currently has Personal Care Services (PCS) 41 hours per week.  Family is paying for a private aide to assist the patient when the personal care aide (PCA) leaves each day.  The patient's daughter is concerned about a decline in the patient's cognitive abilities.  A request was made for PCS 24 hours live-in. 

The Uniform Assessment System (UAS) report indicates the patient needs maximal assistance for all housekeeping related tasks and shopping; extensive assistance for all other Instrumental Activities of Daily Living (IADLs). For Activities of Daily Living (ADLs), she does not walk (moves around her home in wheelchair), needs extensive assistance for most other ADLs, except personal hygiene, eating (limited assistance), bed mobility (supervision). The information regarding her cognitive status is limited.  The physician's letter indicated the patient has cognitive impairment, but no further details provided.  The UAS reports the patient's decision making ability for daily tasks is moderately impaired.  She has short term and procedural memory impairment.  The UAS indicates memory, orientation and decision making declined compared to a previous UAS report.  It is not clear how much of the patient's overall functional impairment is due to cognitive impairment.  It is likely that she has decreased safety awareness and needs her caregivers to provide oversight during care to ensure proper safety during ADLs. 

The patient has physical impairments that affect her ability to perform routine activities.  These impairments are associated with a few of her medical conditions including polyneuropathy and lumbar spinal stenosis/ radiculopathy. Considering the patient's medical history and functional impairment, it is medically necessary to have a caregiver present to provide assistance to the patient for all scheduled activities (routine IADLs and ADLs) and ADLs that occur at unscheduled times during the day and night. It is apparent the patient needs assistance with ADLs through the day and night.

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for PCS; this includes direct care from informal caregivers, and from paid caregivers at the expense of informal caregivers.  Considering the daughter is requesting PCS 24 hours live-in, it is reasonable to conclude that there are no informal caregivers who can provide assistance to the patient on a regular basis through the day and night; and private pay assistance may not be a long term option.  As per NYS regulations for live-in aide services, the patient's need for assistance should be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep in an 8 hour sleep period per day. If the patient's ADLs needs are too frequent to allow for this amount of sleep for the aide, then continuous services are necessary.  The frequency of the patient's evening/nighttime personal care needs can only be assessed based on the 2 nights in the activity log.  Both nights had a period of approximately 5 hours without need for assistance.  The patient needs assistance with all ADLs that extend over the course of the day and night; and so 24 hour services are indicated. Based on the 2 nights recorded in the activity log, an uninterrupted 5 hour interval for sleep for an aide appears possible.  


The carrier's denial of coverage for PCS, 24 hours a day, 7 days per week (live-in), for a total of 91 hours is overturned.  The medical necessity is substantiated.