Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's disease; Dementia.
Treatment:  Increase Personal Care Aide (PCA) hours to 7 days 2 - 12 hours per day (split shift).

The insurer denied coverage for Increase Personal Care Aide (PCA) hours to 7 days 2 - 12 hours per day (split shift).  The denial is overturned.

This female patient has the diagnoses of diabetes mellitus, hypertension, dizziness, dementia, memory impairment, insomnia, carpal tunnel syndrome, impaired balance, unsteady gait, wheelchair bound, bed bound, osteoarthrosis of knees, urinary incontinence, asthma, cervicalgia, low back pain, osteoporosis, and thrombocytosis.

Per encounter notes with the provider, the patient's memory was much worse lately, with episodes of confusion during the day and night.  She was noted to have multiple falls with recent humerus fracture, and severe depression after her husband's death.  She needed to be turned in bed every 2-3 hours to prevent bed sores and needed diapers changed every 2-3 hours.  The Uniform Assessment System (UAS) noted that the patient lives alone, and her cognitive skills were moderately impaired.  She was totally dependent on assistance with bathing, walking, locomotion, toilet transfers/use and dressing lower body.  Maximal assist was required for personal hygiene and dressing upper body, and extensive assistance was required for bed mobility and eating.  The patient had urinary and bowel incontinence.

The care provided by personal care aides (PCA) and/or informal caregivers for turning and positioning and incontinence care is an essential component of the care plan for prevention of skin injury and patient comfort.  In this case, the patient currently has the services of a 24-hour live-in aide providing assistance with instrumental activities of daily living (IADLs) and activities of daily living (ADLs).  The question is whether the patient's care needs can be adequately met with a live-in aide, or whether she need continuous personal care services.

As per NYS regulations for PCA services, in order to qualify for 24-hour live-in aide, the patient's care needs must be sufficiently infrequent that the aide can expect to have 5 uninterrupted hours of sleep within an 8 hour sleep period each day.  If the patient's care needs are of such high frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services are indicated, i.e., split shift.  

This patient is dependent on caregiver assistance for all toileting tasks (including incontinence care) and for bed mobility.  The patient is at high risk for pressure ulcers and incontinence associated skin damage.  Therefore, it is medically necessary for a caregiver to provide pressure relief (repositioning) on a regular basis and prompt incontinence care when needed.  A time interval of 5 hours without repositioning, and up to 5 hours when the patient may have wet, soiled diapers, is beyond an acceptable timeframe for proper skin care, especially in a high risk patient.  

This frequency of care can not be provided by a live-in aide.  Although there is no nighttime activity log, the patient's history and current information from the patient's physician provide reasonable confidence that the patient would benefit from continuous PCA services, i.e., 24-hour split shift. 

The UAS reports that family members were staying with the patient at night when she had PCA 12 hours per day.  Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  Without informal caregivers to provide assistance to the patient when a live-in aide is unavailable during periods of sleep, then the patient's care needs are best served by 24-hour continuous personal care services (i.e., split shift).

PCA services 7 days per week, 2-12 hours per day, (split shift) are medically necessary.  The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

Based on the above the denial of Personal Care Aide (PCA) services 7 days 2-12 hours a week (split-shift) is overturned.