Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Functional decline.

Treatment: personal care services of 24 hours per day, 7 days per week split shift

The insurer is denied coverage for personal care services of 24 hours per day, 7 days per week split shift.

The denial is overturned. 

This female patient has a history of Parkinson's disease, multiple sclerosis, hypertensive heart disease, history of fractures, history of falling and incontinence.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 notes:
"(a) Definitions and scope of services.
(1) Personal care services mean 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 standalone 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."
The Final Determination Notice indicates that the patient has a degree of functional ability re: toileting, ambulation and transfers that is higher than is otherwise noted. She has recently deteriorated. The patient has bladder and bowel (B&B) incontinence with frequent 24-hour needs that can be unscheduled. There are no scheduled informal caregivers. She cannot perform these ADLs (Activities of daily living) on her own. 

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

The carrier's denial of coverage for the personal care services of 24 hours per day, 7 days per week split shift is overturned.  The medical necessity substantiated.