Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's, osteoarthritis, gout
Treatment: Personal Care Aide (PCA), 12 hours per day, 7 days a week
The insurer denied coverage for Personal Care Aide (PCA), 12 hours per day, 7 days a week
The denial is overturned

This geriatric patient has physical and cognitive impairment associated with several medical conditions and needs assistance with daily activities. The patient lives alone and receives Personal Care Aide (PCA) services to assist with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The Uniform Assessment System (UAS) plan indicates the patient receives some informal help from family during non-PCA hours (frequency and specific tasks not noted). The patient was receiving PCA services 6 hours per day, 7 days per week. The patient (via designee) requested an increase of PCA services to 12 hours per day, 7 days per week, which was denied; PCA services were increased to 8 hours per day, 7 days per week. External appeal was requested.

The most recent UAS report for IADLs indicates the patient was totally dependent for ordinary housework, shopping; the patient needed maximal assistance for meal preparation, managing finances, stairs, transportation; extensive assistance for managing medications; and supervision for phone use. For ADLs, the patient needed extensive assistance for bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use; the patient needed setup help for bed mobility, and eating. 

The Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. When the patient needs assistance with toileting, incontinence care, transfer, walking, food/fluids, this is not a stand-alone safety supervision. This is assistance the patient needs for proper and safe completion of ADLs. These care needs must be considered in the determination of the patient's personal care service hours. Considering the patient's medical history and functional status as noted in the available records, it is medically necessary, and in the patient's best interest, to have assistance with all IADLs and ADLs including household tasks, preparation/service of all meals; assist/supervise eating; morning/evening ADLs (bathing, dressing, personal hygiene); unscheduled/recurring ADLs (such as toileting, incontinence care, transfers, walking). Without adequate assistance, the patient is at risk for adverse health and safety events, such as skin damage due to incontinence, falls/injury, nutritional decline, dehydration.

As per the UAS/Service Plan summary, the patient's son and granddaughter provide assistance after PCA hours as needed; but no details are provided as to the specific tasks and how often they assist the patient. Based on the daughter-in-law's letter, it appears family members may have been assisting the patient more frequently during the Coronavirus (COVID) shutdown period, but now family members have returned to work. Considering the request for increase of PCA services is for 12 hours per day, 7 days per week, it is reasonable to conclude there are no informal helpers who can provide care during that period of time each day. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance for daily activities, including ADLs that occur at unscheduled and recurring times throughout the day. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care aide (PCA), 12 hours per day, 7 days a week services is substantiated.