Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Osteoarthritis, and Incontinence.
Treatment: Personal care aide level 2, 24 hours per day split shift.

The insurer denied coverage for personal care aide level 2, 24 hours per day split shift.
The denial is overturned.

This is a female patient with a past medical history of coronary artery disease, hypertension, type II diabetes mellitus, hyperlipidemia, gastroesophageal reflux disease, dementia, depression, anxiety, insomnia, glaucoma, osteoarthritis and urinary incontinence. She is totally dependent for meal preparation, ordinary housework, managing finances, managing medications and shopping. The patient needs maximum assistance with bathing, personal hygiene, dressing her upper and lower body, toilet use and transportation. She needs extensive assistance with walking, locomotion, toilet transfer, bed mobility and eating. The patient's son reported that the patient is ambulating slowly with an unsteady gait, and she uses a walker and receives assistance for ambulation. The patient's provider notes the patient's clinical condition has significantly deteriorated, and the patient should be evaluated for split shift home care services to ensure her safety and stability in the home. She was recently hospitalized due to a diagnosis of hyperglycemia and a urinary tract infection. Personal care aide (PCA) level 2, 24 hours per day split shift services is being requested. She needs care for incontinence and needs turning and positioning regularly. 
	
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.

Uniform Assessment System (UAS) reports note dementia, incontinence and need for high levels of assistance for bed mobility, transfers, ambulation and toileting. The patient has difficulty making her needs known. She is frequently incontinent of bladder and occasionally of bowel. She needs to be turned and positioned regularly. The available documentation does not indicate that a 24-hour live-in aide can be guaranteed 5 hours uninterrupted sleep. This reviewer disagrees with the plan's interpretation of the need for ongoing unscheduled nighttime services. UAS documentation plus the information from the patient's provider and the patient's son (caregiver) support split-shift 24-hour care. 

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

The medical necessity for the requested personal care aide level 2, 24 hours per day split shift is substantiated. The insurer's denial is overturned.