Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 

Treatment: Personal care assistance of 24 hours per day, 7 days per week, split shift.

The insurer denied coverage for personal care assistance of 24 hours per day, 7 days per week, split shift. 

The denial is overturned. 

This is a female patient with a medical history of anxiety, depression, dementia, anemia, heart disease, falling history, insomnia, gait and mobility abnormalities, and osteoarthritis and vitamin deficiency. The Uniform Assessment System (UAS) - New York notes that the patient lives in a 1 bedroom apartment. There are 6 steps to enter and exit the building, and the patient needs to be carried up and down the steps. The building has a working elevator. The patient is having problems with short-term memory and procedural memory, and her decision-making and cognitive abilities have declined. She has decreased safety awareness. She has 24-hour live in services, but her personal care assistant cannot sleep during the night, as required. The patient's daughter is her only caregiver. An increase to personal care assistance of 24 hours per day, 7 days per week, split shift is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 

(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.
(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.
(4) Live-in 24-hour personal care services means the provision of care by one personal care aide for a patient who, because of the patient's medical condition, needs assistance during a calendar day with toileting, walking, transferring, turning and positioning, or feeding and whose need for assistance is sufficiently infrequent that a live-in 24-hour personal care aide would be likely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.

In this case, the patient currently has 24-hour live-in aide. The UAS(uniform assessment system) notes maximal assistance is needed for walking, locomotion and toileting, a change from extensive assistance in the past. The patient's dementia has worsened and she falls repeatedly.  The patient unpredictably and repeatedly gets up at night to urinate. The patient has both sun-downing and panic attacks during the night. In view of the hands-on and unpredictable nighttime nature of the services needed, personal care assistance of 24 hours per day, 7 days per week, split shift is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for personal care assistance of 24 hours per day, 7 days per week, split shift should be overturned. The medical necessity is substantiated.