Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional impairment. 
Treatment: Home Care / Personal Care HHC [Home Health Care] - Level 2 Personal Care Services, 24 hours per day (split-shift) per week. 

The insurer denied coverage for Home Care / Personal Care HHC- Level 2 Personal Care Services, 24 hours per day (split-shift) per week. 

The denial is overturned. 

This is a male patient who has functional impairment due to various medical conditions, and requires assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). He has been receiving personal care services (PCS) 70 hours per week. A request was made for an increase of PCS to 24 hours per day split shift, which was denied by the insurer.  

A Telephonic Uniform Assessment System (UAS) report was done when the patient was residing in the nursing home for rehabilitation. The patient is deaf; and so he was unable to respond directly to questions or provide medical history. The patient's daughters were present and provided information to the UAS nurse. It is not clear whether the patient's functional status for ADLs was reported by family or if information was obtained directly from the nursing home staff. The UAS indicates the patient was totally dependent or needed maximal assistance for all IADLs, except finances (extensive assistance) and phone use (limited assistance). He needed maximal or extensive assistance for all ADLs, except bed mobility and eating (limited assistance). The patient's cognitive status is not fully described in the available records. He has a diagnosis of dementia, but there is no formal cognitive evaluation provided for review. Considering the patient's medical history and functional status, it is medically necessary and in the patient's best interest to have caregiver assistance throughout the day for all routine IADLs and ADLs; and assistance for unscheduled ADLs that occur at various unpredictable times during the day and night (including transfers, ambulation, toileting/incontinence care). Assistance from informal caregivers is voluntary as per New York State regulations for PCS. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide the assistance needed for daily activities, including ADLs that occur at various and unscheduled times throughout the day and night. 
 
The information provided by the daughter in the patient advocate's letter does not include specific frequency of activity during the night. However, it was noted the patient wakes up multiple times at night to use the bathroom; and so he needs assistance with transfers, walking and toileting at night. It is not known if the patient has a bedside commode, but he needs assistance with transfer out of bed and on/off the commode or toilet; and with hygiene after toileting and incontinence. The fact that the patient's daughters changed the PCS hours to nighttime suggests the patient's care needs at night were frequent, and nighttime incidents, including falls, were too high a risk to continue leaving him alone at night. During the day the patient needs assistance with all other daily ADLs, plus the need for meals and housekeeping tasks. It appears unlikely that a live-in aide would be able to have 5 uninterrupted hours of sleep per day and meet all the patient's care needs. Therefore, continuous personal care services (split shift) are medically necessary to ensure the patient has assistance for all daily activities, including scheduled and unscheduled ADLs that occur throughout the day and night. At this time the decision for PCS must be based on the information currently available, which supports the need for PCS continuous services, i.e. split shift. 

The insurer's denial of coverage for Home Care / Personal Care HHC [Home Health Care] - Level 2 Personal Care Services, 24 hours per day (split-shift) per week is overturned. The medical necessity is substantiated.