Appeal type: Medical necessity
Decision: Overturned

Diagnosis: amyotrophic lateral sclerosis (ALS), cardiac arrest, respiratory failure, dysphagia, and muscle weakness.

Treatment 7 days per week, 24 hours per day, continuous care by more than one person of Personal Care Worker (PCW) services, including 25-30 hours of housekeeping services, Private Duty Nursing (PDN), 24 hours per day, continuous care by more than one person, staffed with Registered Nurse (RN) 12 hours shift and Licensed Practice Nurse (LPN) 24 hours shift; occupational therapy (OT) and physical therapy (PT) every other day and RN Case Manager on daily basis to oversee and manage all duties, cares and issues.

The insurer denied coverage for 7 days per week, 24 hours per day, continuous care by more than one person of Personal Care Worker (PCW) services, including 25-30 hours of housekeeping services, Private Duty Nursing (PDN), 24 hours per day, continuous care by more than one person, staffed with RN 12 hours shift and LPN 24 hours shift; occupational therapy (OT) and physical therapy (PT) every other day and RN Case Manager on daily basis to oversee and manage all duties, cares and issues.

The denial is modified.

The patient is an adult male with history amyotrophic lateral sclerosis (ALS), cardiac arrest, respiratory failure, dysphagia, and muscle weakness. The patient has been residing at a Rehabilitation Center, with plans to return to the community. He is ventilator-dependent, has a tracheostomy and is fed via percutaneous endoscopic gastrostomy (PEG) tube. He needs a Hoyer lift and is totally dependent. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; note:

"(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.

The patient is totally dependent and has ongoing skilled needs that are well-documented and not disputed. A cousin and a friend have signed a Letter of Responsibility. The wording of the document and the guidelines established in the PDN Manual indicate that this documentation is required for backup care givers. This reviewer cannot find any statement that these informal caregivers have committed to a set 3 hours/day as primary caregivers. The need for coverage 24 hours/day instead of 21 is established.

There is no medical reason why the need for OT/PT cannot be assessed after discharge, and why the Manager established by the plan is not sufficient. The health plan acted reasonably in part.

The insurer's denial of coverage for 7 days per week, 24 hours per day, continuous care by more than one person of Personal Care Worker (PCW) services, including 25-30 hours of housekeeping services, Private Duty Nursing (PDN), 24 hours per day, continuous care by more than one person, staffed with RN 12 hours per shift and LPN 24 hours shift; occupational therapy and physical therapy every other day and RN Case Manager on daily basis to oversee and manage all duties, cares and issues is modified. Medical necessity is partially substantiated. The denials of the following are overturned: coverage for 7 days per week, 24 hours per day, continuous care by more than one person of Personal Care Worker (PCW) services, including 25-30 hours of housekeeping services, Private Duty Nursing (PND), 24 hours per day, continuous care by more than one person, staffed with RN 12 hours per shift and LPN 24 hours shift. The denials of the following services are upheld: occupational therapy and physical therapy every other day and RN Case Manager on daily basis to oversee and manage all duties, cares and issues.