Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Schizophrenia, hypertension (HTN), lymphedema, hypothyroidism, hypercholesterolemia and obstructive sleep apnea (OSA).

Treatment personal care services (PCS) of 24 hours per day, 7 days per week (split shift).

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

The denial is overturned.

The patient is a female with a past medical history of schizophrenia, hypertension (HTN), lymphedema, hypothyroidism, hypercholesterolemia, obstructive sleep apnea (OSA) requiring bilevel pressure support, bed bound and status-post a transcatheter aortic valve replacement. The patient was hospitalized with congestive heart failure (CHF). Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her healthcare proxy were present on the call. As previously mentioned, the patient had a fall, and she was at the hospital during the UAS-NY. 

Prior to the hospital admission, the patient was receiving 8 hours per day, 7 days per week of services. The patient's healthcare proxy stated the patient will need increased hours and services for nighttime needs. The patient is totally dependent for meal preparation and ordinary housework. The patient needs maximum assistance with managing stairs, shopping, transportation, dressing her lower body, walking and locomotion. The patient uses a wheelchair or scooter for locomotion. It was noted the patient had that one fall in the last 30 days. She needs extensive assistance with managing finances, managing medications, phone use, bathing, personal hygiene, dressing her upper body, eating, toilet transfer and toilet use. The patient is frequently bladder incontinent and occasionally bowel incontinent. The patient needs limited assistance with bed mobility. An increase to personal care services of 24 hours per day, 7 days per week split shift is being requested.

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.

The patient needs assistance in many areas, including transfers. She is incontinent of bladder and bowel. Even though she has been provided with durable medical equipment (DME) she needs assistance in using such items as a commode. She has nighttime incontinence and needs assistance managing her diapers. She also would need assistance using the toilet. 
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 the article "Preventing pressure ulcers", changing diapers regularly and positioning are also necessary. (2)

There are no caregivers at night. The patient has 24-hour unscheduled needs that would be covered by personal care services. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. This reviewer disagrees with the plan's assessment. 

The insurer's denial of coverage for the requested Personal Care Services of 24 hours per day, 7 days per week (split shift) is overturned. Medical necessity is substantiated.