Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, osteoarthritis
Treatment: Personal care aide services 7 days per week, live-in
The insurer denied coverage for personal care aide services 7 days per week, live-in.
The denial is upheld. 

This is a female patient with a medical history of dementia, repeated falls, psychotic disorder with delusions, chronic obstructive pulmonary disease, atrial fibrillation, renal cell carcinoma, urinary tract infections, osteoarthritis, and wedge compression fracture of thoracic (T) spine level T11-T12 vertebra. 

The patient was re-admitted to a short-term rehabilitation facility. Facility notes are inconsistent in functional assessments of the patient. One review notes the patient needs limited assistance with bathing/showering and bed mobility. She needs extensive assistance with ambulation and toileting and limited assistance with personal hygiene. The Skilled Nursing Facility (SNF) Physical and Occupational Therapy Progress Summaries note that the patient is independent or needs only supervision for ambulation, transfers, bed mobility, dressing, bathing and toileting/toilet transfers. Balance and Endurance are good. She will need 24/7 care for cognition and safety problems. 

The most recent notes indicate the patient is not able to safely do her activities of daily living (ADLs). In a detailed letter, it is noted that the patient has unscheduled night-time needs, that is, toileting, bed mobility, transfers and locomotion, such that would not allow an aide to perform them and still obtain an uninterrupted five hours of sleep.

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. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for personal care aide services 7 days per week, live-in is upheld.