Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, hypertension, gastroesophageal reflux disease (GERD), and diabetes.	
Treatment: personal care worker (PCW) services 4 days per week, 19 hours per day (Monday to Thursday), 2 days per week, 10 hours per day (Friday and Saturday), and 1 day per week, 9 hours per day (Sunday) for a total of 105 hours a week.
The insurer denied coverage for personal care worker (PCW) services 4 days per week, 19 hours per day (Monday to Thursday), 2 days per week, 10 hours per day (Friday and Saturday), and 1 day per week, 9 hours per day (Sunday) for a total of 105 hours a week.
The denial is overturned.


This female has experienced significant functional decline associated with various medical conditions and needs assistance with all daily activities. As per UAS (Uniform Assessment System), the patient lives alone in an apartment; daughter lives in attached private home. The patient receives personal care worker (PCW) services 84 hours per week (12 hours per day). The family provides informal care during non-PCW hours (as per UAS, 5 family members take turns assisting patient).  The patient (via designee) requested increase of PCW services to 105 hours per week allocated as 4 days per week, 19 hours per day; 2 days per week, 10 hours per day; 1 day per week, 9 hours per day. 

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple medical conditions. Other factors include social and economic circumstances (e.g., caregiver support). Accelerated periods of decline can occur in response to new/acute medical events. As people age, functional reserve decreases; and when a new medical problem results in further functional decline, it becomes increasingly difficult to return to the prior level of function. Rehabilitation can help, but there may be limits to improvement due to underlying medical conditions. For example, for a person with dementia, improvement may occur with rehabilitation services when therapists are present and provide optimal physical support and verbal cues. However, cognitive impairment can limit the ability of a person to learn, remember and continue to use the skills acquired during therapy; and so, the beneficial effect can diminish after the course of therapy is completed.
As per NYS (New York State) regulations for personal care services, 24-hour care can be provided as live-in services or continuous (split shift) services. In order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8-hour sleep period each day. If the patient's care needs are of such frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services are indicated, i.e., split shift.

Based on the information provided for review, it is medically necessary for the patient to have a caregiver present who is awake and able to provide care promptly when needed throughout the day and night. This is necessary to help prevent falls/injuries, skin damage (from incontinence; pressure), enhance patient's comfort/decrease pain, and possibly alleviate anxiety/agitation and help her sleep.  

Recommendation is given to approve Personal Care Worker services 4 days per week, 19 hours per day; 2 days per week, 10 hours per day; 1 day per week, 9 hours per day; total of 105 hours per week.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for personal care worker (PCW) services 4 days per week, 19 hours per day (Monday to Thursday), 2 days per week, 10 hours per day (Friday and Saturday), and 1 day per week, 9 hours per day (Sunday) for a total of 105 hours a week is overturned. Medical Necessity is substantiated.