Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident (CVA).
Treatment: Personal care services, 24 hours a day, 7 days a week (live-in).
The insurer denied coverage for personal care services, 24 hours a day, 7 days a week (live-in). 
The denial is overturned. 

This is a female patient with a medical history of osteoporosis, heart disease, muscle weakness and urinary incontinence.  The patient has resided at a Skilled Nursing Facility (SNF) following a stroke that resulted in bilateral (b/l) lower extremity (LE) weakness. Her mentation is good. She has infrequent bladder incontinence and no bowel incontinence. She requires at least extensive-maximal assistance with activities of daily living (ADLs) and is totally dependent for transfers and toileting. Physical Therapy (PT) indicate she needs maximal assistance x2 for bed mobility and cannot ambulate. She is alert and oriented. She has infrequent urinary and no bowel incontinence. She needs a Hoyer Lift. The patient lives alone and has no formal or informal supports. 

The insurer has denied coverage for personal care services, 24 hours a day, 7 days a week (live-in) as not medically necessary. 

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.

The patient is status post recent cerebrovascular accident (CVA) with resulting weakness, especially of the lower extremities. She is bedbound and dependent for transfers and toileting. She needs maximal with bed mobility. The patient is at high-risk for pressure damage. In her case turning and positioning is a task that needs to be done regularly, and she needs to be cleaned promptly when needed. The safety and companionship services she receives are not stand-alone. 

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

The insurer's denial of coverage for personal care services, 24 hours a day, 7 days a week (live-in) is overturned. Medical necessity is substantiated.