Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart disease; Reflux; Osteoarthritis.
Treatment: Personal Care Assistance (PCA) services.
The insurer denied coverage for Personal Care Services (PCS) 24 hours, 7 days a week (split-shift).
The denial is upheld. 

This female patient has a history of coronary heart disease, cataract extraction, chest pain, chronic atrial fibrillation, hypertension, gastroesophageal reflux disease, osteoarthritis, shortness of breath, other abnormalities of gait and mobility and urinary incontinence.  She has been receiving personal care aide (PCA) services 5 days a week x 11 hours and 2 days a week x 12 hours as a mutual case with her spouse.  The Uniform Assessment System (UAS) - New York Community Health Assessment Level of Care Report notes that extensive assistance is required for activities of daily living (ADLs), except limited assistance for bed mobility.  Bladder incontinence is noted.  Since the last assessment she has reportedly deteriorated.  An increase in services to 24 hours, 7 days a week (split-shift) is requested.
 
The insurer has denied the coverage indicating that time is not provided when there are no tasks being done, for companionship or for safety supervision.  The patient has been approved to receive 84 total service hours a week (shared with the patient's spouse). 

The patient's physician notes that the patient needs aides 24 hours/day. Logs by her children show need for assistance with toileting once/night. At issue is the medical necessity of personal care services, 24 hours, 7 days a week (split-shift)

Reference is made to the following:

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

(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.
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 stand-alone 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. WGIUPD GENERAL INFORMATION SYSTEM 01/24/03 DIVISION: Office of Medicaid Management PAGE 2 GIS 03 MA/003 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Personal care services, 24 hours, 7 days a week (split-shift) considered are not medically necessary for this patient. 

The patient needs little assistance with bed mobility but extensive assistance with transfers, ambulation and toileting.  She is continent of bowels.  Review of the children's logs reveals that the patient has to urinate once/night and has diapers.  This frequency does not meet the requirement for split-shift that an aide would not be able to expect 5 hours of uninterrupted sleep. 

The insurer's denial of coverage for personal care services, 24 hours, 7 days a week (split-shift) is upheld.  Medical necessity is not substantiated.