Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive and physical impairment. 
Treatment: Personal Care Aide (PCA) Services of 7 days x 24 hours (continuous services) per week. 

The insurer denied coverage for PCA Services of 7 days x 24 hours (continuous services) per week. 

The denial is overturned. 

This is a female patient who lives at home with her daughter. The patient has dementia and multiple other medical conditions resulting in substantial cognitive and physical impairment and needs caregiver assistance for all daily activities. She had been receiving personal care assistant (PCA) services 84 hours per week. The patient (via designee) requested an increase of PCA services to 24 hours per day continuous services. 

The functional status reported in the current Uniform Assessment System (UAS) report indicates the patient is totally dependent on caregivers for all instrumental activities of daily living (IADLs), except stairs and transportation (maximal assistance). The patient needs maximal or extensive (weight-bearing) assistance for all activities of daily living (ADLs), except bed mobility (limited assistance). There was a change in ADL status from the previous UAS to the current UAS. Walking, locomotion, transfer toilet, toilet use were reported as needing extensive assistance in the previous UAS; these ADLs needed maximal assistance, as reported in the current UAS.  There was also a decline in function for eating; the previous UAS indicated limited assistance while the current UAS indicates extensive assistance. The patient has multiple medical conditions that are probable causes of her cognitive and physical impairment and have a substantial effect on her daily function including:  dementia, depression, osteoarthritis, cardiovascular disease, and chronic obstructive pulmonary disease (COPD).  

The insurer noted in their final denial letter that additional PCA time is not allotted for stand-alone safety supervision. The patient needs assistance with all mobility, due to physical and cognitive impairment. When she tries to stand up and walk, she needs hands-on assistance, as she is at risk for falls with transfers and ambulation. This is not stand-alone safety supervision. Assistance and supervision/cues for safety with ADLs is an important aspect of the care provided by personal care aides. 

Considering the patient's medical history and functional impairment, it is medically necessary and in the patient's best interest for the patient to have a caregiver present throughout the day and night to assist with all daily activities, including scheduled activities, unscheduled activities and periodic repositioning for pressure relief. The nighttime activity log demonstrates that assistance with ADLs is needed with such frequency that an uninterrupted 5 hour interval for sleep for a live-in aide appears unlikely on a regular basis. Usual daytime activities would not accommodate a 5 hour interval for sleep (meals, bathing, dressing, hygiene, toileting, incontinence care, out of bed mobility, all household related tasks). It appears the patient's care needs do not meet criteria for live-in services; and therefore continuous services are necessary. 

Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. When informal caregivers are unable to provide care with daily activities on a consistent basis, then personal care services are indicated to provide assistance to the patient for all necessary daily activities, including ADLs that occur at various and unscheduled times through the day and night. 

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

The carrier's denial of coverage for the requested Personal Care Aide (PCA) Services of 7 days x 24 hours (continuous services) per week is substantiated.  The insurer's denial is overturned.