Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Increase Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than one person.

The insurer denied coverage for the increase of Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than one person.  The denial is overturned. 

This is a female patient with a past medical history of dementia, anxiety, atrial fibrillation, coronary artery disease status post coronary artery bypass graft (CABG), hypertension, hyperlipidemia, and colon cancer status post resection.  Per Uniform Assessment System (UAS) documentation, the patient is totally dependent for meal preparation, ordinary housework, managing finances, shopping, bathing, dressing her lower body and toilet use.  She requires maximal assistance with managing medications, personal hygiene, dressing her upper body, bed mobility and eating.  The patient was noted to also be bed bound.  Increasing Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than one person is being requested.

The patient needs assistance with all activities of daily living (ADLs), and that is not an issue.  At issue is the need for a split shift.

As noted in New York Codes Rules and Regulations, Title: Section 505.14 Personal care services:  (a) Definitions and scope of services.  ***2) Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.

The patient is prone to bed sores, having a stage III back ulcer.  She has dementia, and Hospice Nursing Initial Evaluation notes indicate that she picks at diapers and has skin tears.  The People Care note, supporting split shift aide, notes that the aide cannot rely on getting 5 hours of sleep due to the patient's needs.  UAS notes that the patient has deteriorated.  

The health plan did not correctly assess the demands being placed on the aides.  The request for PCW services 7 days per week, 24 hours per day, continuous care by more than one person is considered medically necessary for this patient.  There is documentation that the patient has dementia, is incontinent, and is prone to pressure sores.  It is not reasonable to have her lying in soiled diapers, no matter how effective, for up to 5 hours.  Furthermore, there is documentation that her other needs are not necessarily scheduled, and one aide cannot reliably get 5 hours uninterrupted sleep. 

The carrier's denial of coverage to increase PCW services to 7 days per week, 24 hours per day, continuous care by more than one person is overturned.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.  The medical necessity is substantiated.