Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Generalized arthritis, Chronic pain

Treatment: 24 hours, 7 days a week (Split shift); home health aide (HHA) or consumer directed personal assistance services (CDPAS)

The insurer denied coverage for 24 hours, 7 days a week (Split shift); home health aide (HHA) or consumer directed personal assistance services (CDPAS).

The denial is overturned. 

This is a male patient with a medical history of dementia, uncontrolled diabetes, benign prostatic hyperplasia, other cystostomy status, chronic pain, constipation, fecal urgency, generalized arthritis, hypertension, wandering and falls. A telephonic Uniform Assessment System (UAS) Comprehensive Assessment Report was done. The patient lives alone. He was alert and oriented x 2, and his cognition had declined. There was a history of wandering. Total dependence was required for meal preparation, housework, and shopping. Maximum assistance was required for transportation. Maximal assistance was required for lower body dressing. Extensive assistance was required for bathing, personal hygiene, upper body dressing, walking/locomotion, and toilet transfers/toilet use. The patient was independent/setup help only with bed mobility. Limited assistance was required for eating. His Activities of Daily Living (ADLs) status had declined and overall self-sufficiency had deteriorated since the last assessment. The patient had a suprapubic catheter in place, and required assistance with emptying the leg bag and hygiene post toileting. Occasional bowel incontinence was noted, and he sleeps with diapers. The patient ambulated with an assistive device and extensive assist. Previous UAS notes indicate cognitive decline, but he could be home alone. Nighttime aide logs indicate that catheter care is performed 3-5 times per night in a roughly 8-hour period of time. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 7/6/16 

(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.

Of note, the patient's wife, who was a caregiver at night, has passed away. There are no informal caregivers staying with him. He has progressive dementia. He is confused and needs constant direction/cuing. He needs frequent catheter/ostomy care. He can do it at times, but it is not consistent. There is no reasonable expectation that an aide could get consistent 5 hours of uninterrupted sleep in an 8-hour time frame. The health care plan did not act reasonably and with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for 24 hours, 7 days a week (Split shift); home health aide (HHA) or consumer directed personal assistance services (CDPAS) is overturned. The medical necessity is substantiated.