Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Paraplegia and Pressure ulcers.
Treatment:  Personal Care Assistance (PCA) services, 24 hours a day, split shift (two 12-hour shifts), 7 days a week.

The insurer denied coverage for PCA services, 24 hours a day, split shift (two 12-hour shifts), 7 days a week.  The denial is overturned. 

This is a male patient, who is bed-bound and has a medical history of 4 abdominal aortic aneurysms and paraplegia secondary to stroke following surgical repair, osteomyelitis of vertebra, hypertension, hyperlipidemia, stage 2 pressure ulcers of his bilateral heels, and a stage 4 right ischial ulcer.  He has subsequently required treatment for infections related to an implantable device, pressure ulcers and chronic urinary tract infections.  The patient had recent excision and debridement and muscle flap closure of the right ischial stage 4 pressure ulcer, and clostridium difficile pseudomembranous colitis/diarrhea.  A Uniform Assessment System (UAS) report was done.  The patient's son reported a decline in the patient's status.  Total dependence was reported for bathing, personal hygiene, dressing locomotion, toilet transfers/use and bed mobility.  There is bladder incontinence and frequent bowel incontinence noted.  Maximal assistance was required for eating.  The patient's son is unable to assist. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services:
(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.

The patient is bedbound and would be unable to predictably turn himself every 2 hours as ordered by physicians. He is also incontinent of bowel and the UAS notes the need for him to be cleaned promptly after bowel movements; he cannot do this himself. He already has a stage 4 decubiti which required hospital care and surgery; maintaining skin integrity to the best extent possible is a major goal. 

The health plan did not give sufficient weight to the importance of scheduled services or the need for care after bowel incontinence.  Avoiding pressure changes, infection in already broken-down areas is very important to this patient.  The patient has extensive problems with skin breakdown due to a paraplegic, bed-ridden state.  Turning and positioning needs to be done every 2 hours.  He has bowel incontinence and needs total assistance with cleanup.  This would be unpredictable.  An aide cannot be assured 5 hours of uninterrupted sleep as a result. 

The medical necessity for Personal Care Assistance (PCA) services, 24 hours a day, split shift (two 12-hour shifts), 7 days a week is substantiated.  The insurer's denial is overturned.