Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD), Lung Cancer, Dementia

Treatment: Personal Care Assistant (PCA) hours 7 days x 24 hours mutual continuous services per week
The insurer denied coverage for Personal Care Assistant (PCA) hours 7 days x 24 hours mutual continuous services per week. 
The denial is overturned.
This is a female patient with a medical history of severe pulmonary disease including COPD, lung cancer and is oxygen dependent. Earlier this year she was diagnosed with normal pressure hydrocephalus (NPH). The patient lives with her sister in an apartment. The sister was recently approved for personal care assistant (PCA) 24 hour services. The patient had been receiving PCA services 6 hours per day, 5 days per week. The patient's condition declined in the last few months due to hospitalization for pneumonia, followed by a rehab admission, then returned home. The patient's daughter requested increase of PCA services to 24 hours continuous split shift (mutual case with the sister). The request was denied, and approval stayed at 30 hours per week. However, according to the daughter, the insurer split the sister's hours; and so there is one aide in the home who provides 12 hours of care per day to the sister, and 12 hours per day to the patient. The daughter is concerned because her mother is approved (on paper) for 6 hours per day, 5 days per week; and so if the sister should be hospitalized, then her mother's hours will be reduced to 30 hours per week; as the 24 hour services were approved for the sister.

Over several months the patient has had progressive gait imbalance, urinary incontinence, cognitive decline; CT brain from early 2020 is consistent with normal pressure hydrocephalus (NPH).  Earlier this year patient was hospitalized with COVID-19 infection, went to subacute rehab and is now home. She is oxygen dependent, has limited walking capacity, bladder issues, especially overnight. 24 hour aide is recommended for patient to remain safe at home and avoid future hospitalizations.

The most recent Uniform Assessment System (UAS) provided for review is from early 2020. Since the UAS the patient has had been hospitalized with pneumonia and her conditioned declined. She has dyspnea with minimal activity and is on continuous oxygen. The patient had dyspnea with normal daily activities but did not indicate use of oxygen at that time, frequent urinary incontinence, with complete bowel continence.  Currently the patient is able to use the toilet but is incontinent of bladder and bowel. It is reported the patient could walk 150-299 feet without sitting down; now she becomes short of breath walking a few feet. The functional assessment indicated the patient needed extensive assistance with bathing, lower body dressing, walking, toileting and bed mobility. For Instrumental Activities of Daily Living (IADLs), the patient was totally dependent for household tasks and shopping; extensive assistance with medications, and phone.

Considering her need for nighttime incontinence care (and possibly out of bed for toileting), and repositioning in bed several times during the night, it appears that a live-in aide would not be able to have at least 5 uninterrupted hours of sleep per day, as required by NYS regulations for live-in aides. 
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for denial of coverage for Personal Care Assistant (PCA) hours 7 days x 24 hours mutual continuous services per week is substantiated. The insurer's denial is overturned.