Diagnosis: breast cancer, bone cancer, depression, shortness of breath, dizziness, abnormalities of gait and mobility

Treatment PCW (personal care worker) services 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week

The insurer denied coverage for PCW services 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week

The denial is overturned

The patient is female with a medical history of breast cancer, bone cancer, depression, shortness of breath, dizziness, abnormalities of gait and mobility, pleural effusion, and generalized muscle weakness. Per the Uniform Assessment System (UAS) - New York Comprehensive Community Health Assessment Report, the patient lives alone. Her cognitive skills are severely impaired and are noted to have declined. The patient is frequently incontinent of bladder and bowels, maximal to total dependence is needed for activities of daily living (ADLs) and her overall self-sufficiency is noted to have deteriorated. She has been approved for 24-hour live-in services personal care worker (PCW) services. Split-shift services are requested.

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

(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 dependent for all functions and is incontinent of bladder and bowel. She is unable to care for her toileting needs, and bed mobility is impaired. The need for 24-hour care is not questioned; at issue is whether a live-in aide can provide adequate coverage and get the required sleep. She has already had skin breakdown, and the daughter notes that a live-in aide has already quit due to not getting sleep. The provision of diapers and other durable medical equipment (DME) for incontinence is important but is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" changing diapers regularly and positioning are also necessary. (6)

Given the above circumstances the request for split-shift is approved. 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 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week is overturned. Medical necessity is substantiated.