Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left knee injury. 
Treatment: Home Care / Personal Care - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day live in care. 

The insurer denied coverage for Home Care / Personal Care - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day live in care. 

The denial is overturned. 

This is a female who had a fall at home resulting in left knee injury. The patient went to the Emergency Department; was treated and transferred to a nursing home for short term rehabilitation. In addition to the acute knee injury from the fall, the patient has osteoarthritis. Prior to the fall, the patient received personal care services (PCS) 35 hours per week. For discharge planning, the family requested an increase of PCS to live-in services, which was denied; but PCS hours were increased to 56 hours per week. The patient's current functional status is documented from various sources. The Uniform Assessment System (UAS) report indicates the patient needs maximal assistance for household related tasks and shopping; extensive assistance for all other instrumental activities of daily living (IADLs). For activities of daily living (ADLs), the patient needs extensive assistance for bathing, lower body dressing, toilet transfer and use, walking/locomotion. Other ADLs need limited assistance, except eating (independent setup help). The most recent available Physical Therapy note reports that the patient walks with minimal assistance and walker; transfers with contact guard/minimal assistance. The most recent Occupational Therapy note indicates that for bed mobility, toileting tasks, and transfers, the patient needs contact guard due to unsteadiness; and all need verbal and/or tactile cues. It was also noted that there were continued safety concerns with transfers; and the patient will require assistance for transfers due to arthritic pain in knees. 

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for PCS. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities. As per NYS regulations for PCS, in order to qualify for 24 hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8 hour sleep period each day. If the patient's care needs are of such high frequency that the aide cannot have this amount of sleep on a regular basis, then continuous services are indicated, i.e. split shift. The patient is currently in a nursing home, and staff is available to assist the patient during all shifts. It cannot be determined at this time how frequently the patient will need assistance during evening/night hours when she returns home. However, the records provided for review support medical necessity for caregiver assistance for the patient during day and nighttime hours, as the patient will need assistance for transfers, walking and toileting at various times of the day and night. The patient will benefit from the additional assistance of live-in services when she returns home. The maximum amount of personal care assistant services recommended from this review is limited by the amount requested; in this case, live-in services. When the patient is home her nighttime care needs can be assessed; and if necessary, the plan can be modified. Live-in services are medically necessary at this time. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for Home Care / Personal Care - Level 2 PCS, per 15 minutes increase to 24 hours per day live in care is overturned. The medical necessity is substantiated.