Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus type II (DMII), hypertension, atrial fibrillation (afib), osteoarthritis of knees, lower extremity (LE) pain

Treatment Home Care/ Personal Care HHC (Home Health Care) Level 2 Personal Care Services (PCS) increase to 24 hours per day (split shift)

The insurer denied coverage for Home Care/ Personal Care HHC Level 2 Personal Care Services (PCS) increase to 24 hours per day (split shift)

The denial is overturned

This female is homebound, lives alone, incontinent and unable to care for herself without assistance. She is currently receiving home care 12 hours, 7 days, but this is inadequate; she needs home care 24 hours, 7 days. He has a medical history that includes heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus type II (DMII), hypertension, atrial fibrillation (afib), osteoarthritis of knees, lower extremity (LE) pain, muscle weakness, unsteady gait, dyspnea with minimal exertion, hard of hearing, paresthesia.  She was hospitalized for cerebral infarction and congestive heart failure (CHF) exacerbation; then transferred to inpatient rehab. Assessment by physical therapy (PT)/ occupational therapy (OT) noted patient required maximum assist with 2 person hoyer lift for bed to chair transfer. Patient was also found to be dependent for most activities of daily living (ADLs), meal prep and household chores. Patient is incontinence and unable to maintain personal hygiene without assistance. Patient reports she sleeps all night in a soaked diaper until aide returns in the morning, as she is unable to stand, and is non-weight-bearing. The patient is at high risk for falls, urinary tract infection (UTI), skin tears. Recommendation is for increase of home care to 24 hours, 7 days.

Patient needs assistance for all ADLs except eating (setup help). Braden assessment for pressure ulcers: skin reported as very moist (often but not always moist); walks occasionally but spends majority of day in bed or chair; Friction and shear: requires moderate to maximum assistance in moving, frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance.It was noted that a grandson was a caregiver; but some handwritten notes indicate grandson was available for only one week.
                                                                                
The patient has a supportive family; but the patient needs assistance beyond 12 hours per day, and it does not appear there is sufficient informal caregiver assistance to meet the patient's daily care needs during non-PCA [personal care aide] hours. As per NYS regulations for personal care services, assistance from informal caregivers is voluntary. Considering the family is requesting PCA services 24 hours per day, split shift, it is reasonable to conclude that there are no informal caregivers who can provide care for extended periods of time each day/night to cover this many hours per day and per week. Therefore, personal care services are indicated to provide assistance with all ADLs and IADLs when needed throughout the day and night.

Based on the information provided for review, the patient needs assistance for all daily activities; including those that occur at unscheduled and recurring times during the day and night (including toileting/incontinence care; bed mobility/repositioning for pressure relief). It appears unlikely that a live-in aide would be able to meet all the patient's care needs day and night and have 5 uninterrupted hours of sleep per day on a regular basis. Therefore, PCS 24 hours continuous services (split shift) are indicated. 

Home Care/Personal Care HHC - Level 2 Personal Care Services (PCS), 24 hours per day (split shift) is medically necessary. 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 Home Care/ Personal Care HHC Level 2 Personal Care Services increase to 24 hours per day (split shift) is reversed. Medical necessity is substantiated.