Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, Hyperlipidemia, Hearing Loss, Glaucoma, Osteoarthritis, Dizziness, Gait Instability and Dementia. 

Treatment: Personal Care Services (PCS) of 24 hours a day, 7 days a week (split shift). 

The insurer denied coverage for Personal Care Services of 24 hours a day, 7 days a week (split shift). 

The denial is overturned. 

The patient is a female with a past medical history of hypertension, hyperlipidemia, hearing loss, glaucoma, osteoarthritis, dizziness, gait instability and dementia. The patient was hospitalized due to dizziness from vertigo. She was discharged on Meclizine. Per an expedited New York State Department of Health's Uniform Assessment System (UAS-NY), the patient's daughter reported she presents with signs and symptoms of deconditioning. The patient's daughter also reported the patient requires assistance with all tasks due to generalized weakness, dizziness and an inability to ambulate or stand since her discharge from the hospital. In addition, the patient has occasional forgetfulness. She also has increased incontinence due to decreased functioning and deconditioning since her hospitalization. The patient uses pull ups, but she is unable to take them off in the evening when the personal care aide is not present. She also has complains of body aches. The patient lives alone, but her daughter is temporarily staying with her until the patient is given additional personal care service hours. The patient's daughter assists with tasks when she is able to. An increase to personal care services of 24 hours a day, 7 days a week (split shift) is being requested. 

Needs are: 
- Maximal assistance for meals, shopping, housework, bathing, lower body (LB) dressing, locomotion, transfer toilet; 
- Extensive Assistance for personal hygiene, upper body (UB) dressing, toileting, bed mobility; 
- Limited assistance for eating. 
Cognition: There is mild impairment. 
- Continence: There is frequent urinary as well as bowel incontinence. 

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 has documented cognitive impairment and does not follow instructions well. She has extensive functional limitations as noted above, including with bed mobility, transfers, toileting and walking. She has Durable Medical Equipment but cannot use them independently. She has frequent urinary incontinence. The Uniform Assessment System notes that she was instructed in changing soiled supplies and providing skin care promptly as well as providing good perineal care. She is unable to do these on her own. Using pullups and other Durable Medical Equipment does not replace these other requirements. She cannot manage a bedside commode on her own. 

The patient has unscheduled nighttime needs that are frequent. The family's request is approved. There is no committed caregiver. 

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 interpretation of the patient's needs, especially at night. 

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