Diagnosis: Neurodegenerative dementia and physical deconditioning.
Treatment: Personal Care Services (PCS) Level 2, 24 hours per day, 7 days per week (live-in).
The insurer denied coverage for Personal Care Services (PCS) Level 2, 24 hours per day, 7 days per week (live-in).
The denial is upheld.

This is a female patient with a past medical history of mixed vascular disease, neurodegenerative dementia with behavioral disturbance, cerebral microvascular disease, mood disorder, physical deconditioning, hypertension, malignant neoplasm of the breast, hearing loss, malignant neoplasm of the adrenal gland, aortic valve regurgitation, abnormal gait, carotid bruit, hyperlipidemia and atrial fibrillation. An increase to personal care services (PCS) Level 2, 24 hours per day, 7 days per week (live-in) is being requested.

Based on the patient's medical history and functional status prior to a recent hospitalization and rehab facility admission, the patient needs assistance with all daily activities; and with very limited informal help, she is dependent on personal care services for assistance with all daily activities. She needs assistance with all instrumental activities of daily living (IADLs). This includes preparation and service of all 3 meals per day to ensure the patient is not skipping meals due to inability to prepare/serve a meal, or forgetting to eat. She needs activities of daily living (ADLs) assistance for bathing daily; and personal hygiene and dressing morning and evening. She needs assistance for toileting and incontinence care which occurs at various unscheduled times of the day and night. The patient's mobility is impaired, and she needs help with transfers and walking around her home to help decrease occurrence of falls. She needs verbal cueing/prompting in addition to physical assistance to ensure safe performance of mobility and other ADLs.

As per New York State (NYS) 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 available information, there are serious concerns as to whether 24 hour live-in services can meet all of the patient's care needs. There is insufficient information of the patient's current medical and functional status and discharge plan from the rehab facility to determine whether personal care services can meet the patient's care needs at home, and the amount of services needed.

The medical necessity for personal care services cannot be determined at this time.
The insurer's denial of coverage for the requested Personal Care Services (PCS) Level 2, 24 hours per day, 7 days per week (live-in) is upheld.