Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, depression and anxiety

Treatment: increase in hours in personal care aide (PCA) services from thirty-four (34) hours per week to eighty-four (84) hours per week

The insurer denied coverage for increase in hours in PCA services from 34 hours per week to 84 hours per week

The denial is reversed

This elderly patient has experienced physical and cognitive decline and relies on caregivers for assistance with most daily activities. The patient lives with her husband who has been the primary informal caregiver. The patient receives PCA services 34 hours per week. Letters provided by the patient's son and the husband's physician indicate the husband is no longer able to provide the level of care the patient needs during non-PCA hours. The patient (via designee) requested increase of PCA services to 84 hours per week. 

The most recent Uniform Assessment System (UAS) report was reviewed. The functional status report indicates the patient is totally dependent for ordinary housework; she needs maximal assistance for meal preparation, shopping, transportation; extensive assistance for managing medications and finances, phone use, stairs. For activities of daily living (ADLs), the patient needs extensive assistance for bathing, dressing lower body, toilet use; limited assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet; setup help for bed mobility, eating.

Currently, the patient has PCA services 34 hours per week, approximately 5 hours per day. It was reported that the patient's husband is having difficulty assisting the patient with daily activities, including toileting related tasks. If the husband is unable to safely assist the patient, this can lead to falls in the bathroom which are associated with increased risk of injury in older people. If the patient remains in soiled, wet diapers for an extended period of time, this can lead to incontinence associated skin damage (e.g. dermatitis, fungal infection). The patient also has episodes of bowel incontinence (as reported by physician) which can increase risk of urinary tract infection. 

In order to facilitate safe, effective completion of toileting related tasks, and help prevent complications (e.g. falls, skin damage), the patient needs a caregiver who can provide assistance with toileting and incontinence care throughout the day. It does not appear the husband can safely manage these tasks.

Based on the information provided by the patient's son and from the husband's physician (in a separate letter provided for the appeal), it appears the patient's husband is not able to continue as an informal helper for the patient's ADL care needs on a regular basis. 

Assistance from informal caregivers is voluntary as per New York State (NYS) 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 instrumental activities of daily living (IADLs), routine ADLs, and ADLs that occur at unscheduled and recurring times throughout the day. Increase of PCA services to 84 hours per week, 12 hours per day will provide the patient with necessary help for all ADLs and IADLs during daytime/evening hours.

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

The insurer's denial of coverage for the increase in hours in PCA from thirty-four (34) hours per week to eighty-four (84) hours per week is reversed. Medical necessity is substantiated.