Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transient ischemic attack, coronary artery disease, hypertension, diabetes mellitus, hypothyroidism

Treatment personal care worker (PCW) services of 7 days per week, 24 hours per day continuous split shift by more than 1 person for a total of 168 hours per week

The insurer denied coverage for personal care worker (PCW) services of 7 days per week, 24 hours per day continuous split shift by more than 1 person for a total of 168 hours per week.

The denial is overturned.

The patient is of advanced age with a past medical history of a transient ischemic attack, coronary artery disease, hypertension, diabetes mellitus, hypothyroidism, hyperlipidemia, dementia, urinary incontinence, back and knee pain, shortness of breath, decreased vision and difficulty walking. The patient lives alone and is bed bound. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her son were present on the call. She is totally dependent for ordinary housework, managing finances and shopping. The patient needs maximum assistance with meal preparation, managing medications, bathing, dressing her lower body and toilet use.  The patient is frequently bladder incontinent and infrequently bowel incontinent.  She needs extensive assistance with phone use, managing stairs, transportation, equipment management, personal hygiene, dressing her upper body, toilet transfer and bed mobility. The patient needs limited assistance with walking, eating and locomotion. She uses an assistive device for locomotion. She has visual and hearing impairment. It was noted that the patient had two or more falls in the last 30 days. She has some cognitive impairment that has gotten worse. 

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.

Night logs show multiple episodes of incontinence, changing of diapers, transferring the patient and turning and positioning. 

The patient received physical therapy. She needed contact assistance with multiple functions. 

In summary, this is a patient with visual and hearing deficits as well as physical impairments. She is incontinent, and while pads provide better protection than they used to, they are not enough, especially in someone who has had some signs of skin breakdown. She cannot be expected to change diapers when soiled.

The provision of diapers and durable medical equipment such as alternate pressure beds is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers," changing diapers regularly and positioning are also necessary. 

The patient has unscheduled tasks at night that require assistance beyond safety or supervision only. There was sufficient evidence to support that Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day continuous split shift by more than 1 person was considered medically necessary treatment for the patient's condition.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day continuous split shift by more than 1 person for a total of 168 hours per week is overturned. Medical necessity is substantiated.