Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hyperlipidemia, osteoporosis and metastatic stage IV breast cancer.

Treatment personal care worker (PCW) services of 24 hours per day, 7 days per week, live in.

The insurer denied coverage for personal care worker (PCW) services of 24 hours per day, 7 days per week, live in.

The denial is overturned.

The patient has a past medical history of dementia, hyperlipidemia, osteoporosis and metastatic stage IV (4) breast cancer. The patient lives in a private home with her daughter. The patient wandered away from her home while her daughter was at work. The patient was found approximately 10 minutes away from her home.  The patient was offered Haldol medication for confusion and a dementia workup, but the patient's daughter declined and stated they would return to the hospital if the patient's symptoms worsened.  The patient's daughter, who is also a social worker, submitted a request to the insurer for an increase in personal care services due to the patient's cognitive decline and the wandering episode.  

Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her daughter were present on the call. 

Needs are: 

- Maximal assistance for meal preparation, ordinary housework and shopping.
- Extensive Assistance for managing finances, managing medications and transportation. 
- Limited assistance with phone use, managing stairs, equipment management, bathing, dressing her upper and lower body, eating and toilet use.
- Supervision/Independence for personal hygiene, walking, toilet transfer, locomotion and bed mobility.
- Cognition: 	There is mild impairment. 
- Continence: 	There is infrequent urinary and no bowel incontinence. 

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."

The patient has significant dementia manifesting as wandering and cognitive problems. She also is incontinent. The last tasking tool was a while ago. She needs assistance with toileting including handling pull-ups. She would not be able to initiate and execute getting to bathroom without assistance. The provision of diapers and durable medical equipment (DME) such as alternate pressure beds is not by itself adequate for prevention of pressure sores. 

She would have infrequent nighttime needs, and an aide could expect 5 hours of sleep. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Worker (PCW) Services of 24 hours per day, 7 days per week, live in is reversed. Medical Necessity is substantiated.