Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure (CHF), chronic obstructive airway disease (COPD), anemia, renal failure, hypertension	

Treatment: Home care I Personal care HHC (home health care) - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift)

The insurer denied coverage for Home care I Personal care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift).

The denial is overturned.
	
This female has an extensive medical history associated with substantial functional impairment. She depends on caregivers for all daily activities. The patient's family has provided some informal assistance, but she relies primarily on personal care services (PCS) for all instrumental activities of daily living (IADL) and activities of daily living (ADL). 

Incontinence occurs at unplanned times of the day and night. The patient may remain clean and dry for a few hours, or she may urinate or defecate within an hour of the prior diaper change. There are complications of incontinence, especially for an elderly person dependent on caregiver assistance. Remaining in wet soiled diapers for several hours can result in incontinence associated skin damage (e.g., dermatitis, fungal infection) and is associated with increased risk of pressure ulcers.  A possible complication of bowel incontinence is urinary tract infection. For a person with dementia, infection can increase risk of delirium, which is associated with further cognitive decline.

The patient has chronic pain and one way to help relieve some types of pain is by repositioning the patient. With history of osteoarthritis and back pain, it is likely that the patient may experience pain due to prolonged periods of time in one position that places stress on her spine and/or joints. She is dependent on caregivers for bed mobility, and if she is in an uncomfortable position, she relies on a caregiver for repositioning. For a person with chronic pain, and cognitive and physical impairment limiting ability for self-help with pain control, it is necessary to have a caregiver present to help with pain management. 

There is no information available to suggest that the patient's family or any other informal caregiver can provide assistance to the patient while a live-in aide is sleeping. The daughter-in-law has provided some care; however, a letter from the physician indicates the daughter-in-law is very supportive but is unable to provide the care the patient needs. Considering the request for increase of personal care services is for 24 hours split shift, it is reasonable to conclude that there are no informal caregivers who can provide ADL assistance to the patient for extended periods of time of the day or night on a regular basis. As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance when needed for daily activities, including ADLs that occur at various unscheduled and recurring times throughout the day and night.

Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes, 24 hours per day (split shift) is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the home care I Personal care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift) is substantiated. The insurer's denial is overturned.