Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease; Diabetes; Chronic Kidney Disease. 
Treatment: Personal Care Assistance (PCA) services. 

The insurer denied coverage for Personal Care Services (PCS) 24 hours, 7 days a week (split-shift). 
The denial is overturned. 

This male patient has Alzheimer's disease, hyperlipidemia, hypertension, malignant neoplasm of unspecified kidney, chronic kidney disease, diabetes, glaucoma, cervical radiculopathy, pressure ulcer, urinary incontinence, fecal urgency and falls. He has been receiving personal care aide (PCA) services 5 days a week x 11 hours and 2 days a week x 12 hours as a mutual case with his spouse.  The Uniform Assessment System (UAS) - New York Community Health Assessment Level of Care Report notes that maximal to total assistance is required for activities of daily living (ADLs).  An increase in services to 24 hours, 7 days a week (split-shift) is requested. 
 
The insurer has denied the coverage noting that time is not provided when there are no tasks being done, for companionship or for safety supervision. 

The appeal letter noted that the patient is bedbound and requires assistance for unscheduled tasks that occur overnight.  The patient's physician notes that the patient needs 24 hours/day aide.  He needs assistance with multiple instrumental activities of daily living (IADLs). 

The patient's children's logs show at least one episode of bowel incontinence/night (in contrast to UAS that states this is occasional).  He needs total assistance with those and needs positioning in bed. 

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. 
Also: 
"...s previously advised, social services districts are NOT required to allot time for safety monitoring as a separate task as part of the total personal care services hours authorized (see GIS 99 MA/013, GIS 99 MA/036). However, districts are reminded that a clear and legitimate distinction exists between "safety monitoring" as a non-required independent stand-alone function while no Level II personal care services task is being provided, and the appropriate monitoring of the patient while providing assistance with the performance of a Level II personal care services task, such as transferring, toileting, or walking, to assure the task is being safely completed. WGIUPD GENERAL INFORMATION SYSTEM 01/24/03 DIVISION: Office of Medicaid Management PAGE 2 GIS 03 MA/003... 
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The plan did not use up-to-date information about the patient's status. 

The patient has dementia and multiple medical co-morbidities.  He has a percutaneous endoscopic gastrostomy (PEG) and suprapubic catheter.  He is bedbound and is incontinent of bowels at night.  He needs to be cleaned and re-positioned; he cannot do these himself.  Using diapers is not enough.  He has a past history of pressure ulcers, and is at high-risk for recurrence.  The patient has unscheduled nighttime needs, and there are tasks to be performed around the clock. 

The insurer's denial of coverage for personal care services, 24 hours, 7 days a week (split-shift) is overturned.  Medical necessity is substantiated.