Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Chronic pain, Vision loss, Cardiovascular disease.

Treatment: Personal Care Aide (PCA) Level 2 services, live in per diem - 24 hours per day, 7 days per week

The insurer denied coverage for PCA Level 2 services, live in per diem - 24 hours per day, 7 days per week.

The denial is overturned. 

This is a female patient who has an extensive medical history and substantial functional impairment requiring assistance with all daily activities. The patient lives at home with her husband. The patient receives personal care aide (PCA) services 59.5 hours per week. The family arranged for a private aide to stay with the patient at night. The daughter requested an increase of PCA services to 24 hours per day, live-in, which was denied by the insurer. 

The Uniform Assessment System (UAS) report indicates the patient is totally dependent or needs maximal assistance for all instrumental activities of daily living (IADLs). The patient is totally dependent or needs maximal assistance for all activities of daily living (ADLs). There was no significant change in IADLs or ADLs function compared to a previous UAS report. The patient's medical history includes: dementia, chronic pain, vision loss, and cardiovascular disease. Considering the patient's medical conditions and extensive functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present 24 hours per day to provide assistance with ADLs when needed, including nighttime care, e.g. assistance with toileting/incontinence care; and bed mobility for change in position for pressure relief; and when needed, for pain relief.

As per New York State (NYS) regulations for live-in aide services, the patient's need for assistance should be sufficiently infrequent to allow a live-in aide to have 5 uninterrupted hours of sleep in an 8 hour sleep period each day. If the patient's care needs are too frequent to allow for this amount of sleep for an aide, then continuous PCA services are indicated. The records provided for review do not include a nighttime activity record that describes the frequency of assistance needed at night. However, based on the available records, it is apparent the patient cannot be left alone through the night. The patient needs assistance with ADLs for toileting/incontinence care and bed mobility during the evening/night, and she is unable to provide self-care. The family is supportive and involved in the patient's care; but it does not appear there are informal caregivers who can provide extended hours of care each day. The physician reported the husband is ill and there is no indication in the available records of any assistance that he can offer. The family has provided a private aide for the hours the PCA is not with the patient, but it cannot be assumed or expected that this is a long term plan. Considering the family requested 24 hour live-in PCA services, it is reasonable to conclude that the current arrangement with the private aide cannot be maintained indefinitely.

Assistance from informal caregivers is voluntary as per 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 the patient with assistance for daily activities when necessary throughout the day and night. The maximum amount of hours that can be approved from this review is limited by the amount requested, as per the insurer's final adverse determination notice, i.e. 24 hours live-in services. 

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

The carrier's denial of coverage for the requested PCA Level 2 services, live in per diem - 24 hours per day, 7 days per week is overturned. The medical necessity is substantiated.