Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia without behavioral disturbance, and Bowel and bladder incontinence. 
Treatment: Personal Care Services (PCS), 24 hours a day split shift (two 12-hours shift), 7 days a week. 

The insurer denied coverage for Personal Care Services (PCS), 24 hours a day split shift (two 12-hours shift), 7 days a week. 

The denial is overturned. 

This is a female patient with a medical history of dementia without behavioral disturbance, recurrent major depression, bronchiectasis and closed wedge compression fracture. The Uniform Assessment System (UAS) - New York Comprehensive Community Health Assessment Report notes multiple falls, recent hospitalization for fall with spinal compression fracture, memory impairment, and needs for assistance with activities of daily living (ADLs), including personal hygiene, bed mobility and transfers. Bowel and bladder incontinence are also noted for this patient. 

As per the 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. 

Due to the multiple co-morbidities, the patient needs extensive-maximal assistance with activities of daily living (ADLs). Hospital discharge notes indicate that the patient has baseline confusion. The patient care logs reveal that the patient is incontinent multiple times during the night. Use of pull-ups does not change the need for cleaning. The patient is at higher risk of decubiti due to lack of bed mobility and need for positioning. The patient's night-time needs would not allow for five hours of uninterrupted sleep. 

Personal Care Services (PCS), 24 hours a day split shift (two 12-hours shift), 7 days a weeks is considered medically necessary for this patient. 

The insurer's denial of Personal Care Services (PCS), 24 hours a day split shift (two 12-hours shift), 7 days a week should be overturned.