Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Coronary Artery Disease, Diabetes Mellitus, and Hypertension
Treatment: level 2 Personal Care Services (PCS), per 15 minutes, increase to 24 hours per day (live-in)
The insurer denied coverage for level 2 Personal Care Services (PCS), per 15 minutes, increase to 24 hours per day (live-in)
The denial is overturned

This elderly female has substantial functional impairment resulting in difficulty performing daily activities. She needs assistance with all instrumental activities of daily living (IADLs) and activities of daily living (ADLs). The patient lives alone. The patient's care manager reported the patient was paying privately for 24-hour live-in aides for 112(half) years. When the patient became a member of Managed Long Term Care (MLTC) plan, she started receiving personal care services; but approved hours were less than live-in services. The patient's family has been paying privately for aide services during non-PCS hours. Most recently, the patient has been receiving PCS 58 hours per week. 

The most recent Uniform Assessment System (UAS) provided for review was done. The functional status report indicates the patient is totally dependent for most IADLs, except stairs (maximal assistance). For ADLs, the patient needs maximal assistance for bathing, personal hygiene, dressing upper/lower body; extensive assistance for walking, locomotion, toilet transfer, toilet use, eating; limited assistance for bed mobility.

The need to use the toilet and episodes of incontinence occur at variable unplanned times of the day and night. The patient currently has PCS 58 hours per week (approximately 8-9 hours per day). The patient needs to use the toilet or has episodes of incontinence during the other 15-16 hours of the day. Even with use of incontinence products with higher absorption; it is unrealistic to expect the patient will consistently stay clean and dry during non-PCS hours when she has no assistance. Most likely, she would remain in a wet soiled diaper for extended period of time until the aide returns in the morning. Due to discomfort, she may try to get up from bed. Wearing a wet soiled diaper for an extended period of time is inconsistent with basic medical and nursing practice principles for incontinence and skin care. A better plan for managing the patient's toileting and incontinence care is a caregiver who assists with toileting/incontinence care during the day and night to keep the patient clean, comfortable, and help prevent skin damage, infection, and falls.

MLTC policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. These care needs must be considered in the determination of the patient's personal care service hours. 
The patient's son (as patient designee) requested PCS 24 hours per day live-in services. As per New York State (NYS) regulations for personal care services, a live-in aide needs to have 5 uninterrupted hours of sleep within a total of 8 hours sleep per day. There are no detailed evening/night activity logs provided for review. The privately hired night aide indicated the patient needs help with toileting 3-4 times per night, though the intervals between episodes of care are not noted. Based on information from the UAS and letters from the patient's son, aide, and care manager, it is medically necessary for the patient to have caregiver assistance for ADLs that occur during day, evening, and nighttime hours to prevent adverse health and safety events as previously noted in this review. Even though a live-in aide is not providing continuous care, the aide is present and can provide care multiple times through the evening and night (which is not available to the patient with current personal care services 58 hours per week). 

Based on the above, the insurer's denial is overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for level 2 Personal Care Services (PCS), per 15 minutes increase to 24 hours per day (live-in) services is substantiated.