Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cognitive and Physical Impairments. 
Treatment: Personal Care Assistant (PCA) Services of 7 days times 24 hour (continuous service) per week. 

The insurer denied coverage for PCA Services of 7 days times 24 hour (continuous service) per week. 

The denial is modified. 

This is a female patient who was hospitalized for right femur fracture, status post open reduction internal fixation (ORIF); then transferred to a nursing home for subacute rehabilitation (rehab). The patient improved with physical and Occupational Therapy (OT) and was discharged from rehab services. The plan is for the patient to return home, but she cannot be discharged until a safe discharge plan is established. As per the physician's letter and patient advocate's report, the patient lives with her son. The physician noted that the son in unable to provide care for his mother due to other responsibilities. Personal Care Assistant (PCA) services were authorized by the insurer for 8 hours per day, 7 days per week (56 hours per week). A request was made for an increase of PCA services to 24 hours continuous service. 

Uniform Assessment System (UAS) documentation was provided for review. The patient's functional status for instrumental activities of daily living (IADLs) includes total dependence for housekeeping related tasks, meal preparation, shopping and finances; and maximal or extensive assistance for all other IADLs. The patient needed extensive assistance for bathing, dressing lower body, walking/locomotion, toilet transfer/use; supervision for personal hygiene, dressing upper body, eating; and setup help for bed mobility. The UAS and nursing home records include diagnosis of dementia; noted as vascular dementia in the UAS, and probably associated with patient's history of cerebrovascular disease and hypertension. It appears the patient has significant cognitive impairment based on description of cognitive function in the UAS, physician letters and Physical Therapy (PT)/ OT notes. The patient has physical impairments that limit her ability for activities of daily living (ADLs); but cognitive deficits also affect her ADLs. Providing assistance and supervision/cues for safety during ADLs care is necessary and included in the scope of practice for personal care aides. 

As per New York State (NYS) regulations for personal care services, 24 hour care can be provided as live-in services or continuous (split shift) services. In order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8-hour sleep period each day. If the patient's care needs are of such frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services are indicated, that is, split shift. 

The following determination is based on the records provided for this review, which did not include nursing home records within the past few weeks. The patient's physician will determine when the patient is medically stable for discharge. The physician and nursing home staff involved in discharge planning will provide the final determination of the safety of the discharge plan. 

PCA services 7 days x 24 hours (continuous service) is upheld. With the understanding that the patient will be medically stable at the time of discharge, Live-in 24 hour PCA services x 7 days per week is medically necessary. The insurer approved 8 hours per day/ 7 days per week is not sufficient to meet the patient's needs. The health plan did not act in the best interest of the patient. 

The insurer's denial of coverage for the requested PCA Services of 7 days times 24 hour (continuous service) per week is modified. Medical necessity is partially substantiated.