Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease, coronary heart disease, peripheral vascular disease, gastroesophageal reflux disease. 

Treatment home care / personal care HHC [home health care] - level 2 personal care services of 24 hours per day (split shift). 

The insurer denied coverage for home care / personal care HHC - level 2 personal care services of 24 hours per day (split shift). 

The denial is overturned. 

The patient is a female with a past medical history of chronic obstructive pulmonary disease, coronary heart disease, peripheral vascular disease, gastroesophageal reflux disease, colitis with percutaneous endoscopic gastrostomy (PEG) dependence for feedings, type II diabetes mellitus, dementia, depression and general muscle weakness. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, her daughter, social worker, physical therapist and nurse were present on the call. The patient is currently at a SNF [skilled nursing facility]. The patient lives alone in a one bedroom apartment of a senior building with elevator access. Her sister lives across the street from the senior building and can assist, as needed. 

Needs are: 

-Total dependence for meal preparation, ordinary housework, managing stairs, transportation, equipment management, dressing her lower body and toilet use; 
-Maximal assistance for managing medications, shopping, bathing and eating, walking and transferring. 
-Extensive Assistance for managing finances, phone use, dressing her upper body, locomotion (uses mainly wheelchair and needs assistance) and toilet transfer; 
-Limited assistance for personal hygiene and bed mobility ; 
-Cognition: There is mild impairment. 
-Continence: There is frequent urinary and bowel incontinence (chronic diarrhea).  She uses pull-ups. 
-PEG Care: Done by family. 

An increase to home care / personal care HHC - level 2 personal care services of 24 hours per day (split shift) is being requested. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes: 

"(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 care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The need for 24-hour care is not an issue. What is being questioned is her need for split-shift vs. live-in. 

The patient has dementia and extensive physical limitations. She is frequently incontinent of bowel and bladder. She cannot manage getting out of bed and toileting without extensive assistance. The same is true for managing soiled pull-ups. 

The provision of diapers and durable medical equipment (DME) 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.

Given the above picture, it is highly unlikely that a caregiver would get 5 hours sleep uninterrupted if the patient is not to be left potentially for hours in soiled pull-ups. 

The insurer's denial of coverage for the requested Home Care / Personal Care HHC - Level 2 Personal Care Services of 24 hours per day (split shift) is reversed. Medical necessity is substantiated.