Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, diabetes mellitus, and dementia

Treatment: Personal Care Aide - Level 2 services (Live-In), 7 days per week

The insurer denied coverage for Personal Care Aide - Level 2 services (Live-In), 7 days per week as not medically necessary.

The denial is overturned.

The patient is an elderly male with a history of congestive heart failure, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, diabetes mellitus, and dementia. The Uniform Assessment System (UAS) report showed there were mild cognitive impairments. He needed maximal assistance with Instrumental activities of daily living (IADLs) and extensive assistance with activities of daily living (ADLs) except supervision with bed mobility. He has durable medical equipment (DME). There is rare urinary incontinence. 

He receives personal care aide (PCA) services from Visiting Nurse Service of New York (VNSNY) at 8 hours per day, 7 days per week. The request is for an increase to PCA - Level 2 services (Live-In), 7 days per week.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 note:

"(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.

As noted above the patient needs extensive assistance with all ADLs. He needs a Hoyer Lift. Incontinence has been noted, and his sacral skin shows early signs of pressure changes. He is in hospice and his current needs are noted on several hospice RN (registered nurse) home visits. The degree of assistance he needs, the deterioration he has had and the presence of the beginning of skin breakdown all support the need for live-in aide. 

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 Personal Care Aide - Level 2 services (Live-In), 7 days per week is overturned. Medical necessity is substantiated.