Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Behavioral disturbances, hypertension and coronary artery disease.

Treatment: Personal care aide (PCA) services of 7 days per week, 2-12 hour shifts per day (split shift).

The insurer denied coverage for personal care aide (PCA) services of 7 days per week, 2-12 hour shifts per day (split shift).

The denial is upheld.

The patient is male with a past medical history of cognitive impairment with behavioral disturbances, hypertension and coronary artery disease.  Per the New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, his daughter and personal care aide were present during the assessment.  The patient has impaired cognition, and his daughter and son make all the decisions on his behalf.  The patient lives with his daughter in a private home with 1 full flight of stairs to get to the main floor and the bathroom.  Per the patient's daughter, the patient has diagnoses of depression and anxiety which are being treated with medication.  The patient's change in activities of daily living status compared to 90 days ago has declined.  His overall self-sufficiency has also deteriorated compared to 90 days ago. 

Needs noted in UAS are:
 
1) Total dependence for housework and shopping ;
2) Maximal assistance for meal preparation, managing finances, managing medications, phone use, managing stairs, equipment management and dressing his lower body ;
3) Extensive Assistance for transportation, personal hygiene, dressing his upper body, walking (AD), locomotion, toilet transfer and toilet use ;
4) Limited assistance for bed mobility and eating;
5) Cognition:  There is impairment. 
6) Continence:  There is urinary and bowel incontinence.  He wears briefs. 

A Nighttime Needs log is done.  There are no episodes of incontinence or agitation.  He makes his bathroom and other needs known, and the aide does not enter the bathroom with him.  There is no documentation of any resultant problems with toileting.  He is in and out of bed and couch multiple times/night; he needs hand-held assistance with multiple navigations of stairs at night.  He repeatedly walks around living room and kitchen. He does not need turning and positioning. 

The functional assessment from the UAS points to the need for coverage. On the other hand, the nighttime needs log paints a very different picture. Unless the patient was receiving Level II services that were not specified in the nighttime needs log, his mobility, bathroom awareness and apparently independent bathroom function noted in the log seemed quite good. In that case safety is a stand-alone service that is not covered. It was noted there was handhold on the stairs. The needs log indicates good ambulation, so how important the handhold is not clear.   

The available information fails to document the extent of need for 2-12 hour shifts per day.  In the absence of those services the increase in coverage is not supported. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Services of 7 days per week, 2-12 hour shifts per day (split shift) is upheld.  Medical necessity is not substantiated.