Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, heart failure, hypercholesterolemia, hypothyroidism, iron deficiency anemia, depression, constipation, osteoporosis, right wrist/hand fracture, low back pain, urinary incontinence, GERD, UTI, macular degeneration, and bilateral hearing loss

Treatment: Personal Care Aide (PCA) services, 5 days per week, and 24 hours per day (live-in)

The insurer denied coverage for Personal Care Aide (PCA) services, 5 days per week, and 24 hours per day (live-in). The denial was reversed.

This patient is a female who lives alone. Her diagnoses include hypertension, heart failure, hypercholesterolemia, hypothyroidism, iron deficiency anemia, depression, constipation, osteoporosis, right wrist/hand fracture, low back pain, urinary incontinence, GERD, UTI, macular degeneration, and bilateral hearing loss. The patient had a Uniform Assessment System (UAS) in late 2019. The patient is at high risk for adverse medical events due to her medical conditions (e.g. acute cardiac events; sepsis, delirium from UTI). She is also high risk for falls. Risk factors include: unsteady gait, dizziness, weakness, vision loss, incontinence, pain, cognitive impairment, use of medication that can increase fall risk (e.g. antihypertensive drugs). The patient requires substantial assistance for IADLs and ADLs. She lives alone with part-time assistance from PCA and family. 

The risk of some complications can be reduced by modifying certain factors.  For example, the patient has CHF which has resulted in several hospitalizations. As per physician assessment, diuretics are not used because this would increase fall risk when patient is alone due to frequent need for toileting. Patient cannot transfer and walk to commode or bathroom without assistance. She cannot provide self-care for toileting/incontinence. Sleep studies noted several transfers to bathroom/commode and need for incontinence care from evening through early morning. Transfer out of bed to bathroom/commode required substantial assistance. She is at high risk for falls and injury if she tries to get up without assistance and is at high risk for incontinence associated skin injury if she remains in wet, soiled pads and clothes. In addition, the UAS indicates extensive assistance is needed for bed mobility, and so when the patient is in bed for extended periods, she needs to be repositioned on a regular basis to decrease risk of pressure ulcers. Fall related injuries (e.g. fractures, head injury) and skin ulcerations could have critical outcomes for this patient; and so there are difficult decisions to be made to manage the patient's overall health and safety.

However, the risk of injury should not have to be weighed against the risk for acute medical events (such as cardiac decompensation) when there is a reasonable plan to reduce risk of falls/injury related to toileting and incontinence. The plan includes providing the patient with assistance for toileting and incontinence care throughout the day and night. This situation is a useful example that demonstrates the expanded range of adverse consequences that can occur as a result of insufficient caregiver support.

It is apparent from the records that the patient needs assistance for ADLs that occur at various and unscheduled times of the day and night, i.e. transfer, walking, toileting/incontinence care; and therefore needs a caregiver available to assist with ADLs throughout the day and night. 

The UAS indicates that family has been providing some care when the PCA is not present, but the exact time commitment is not known. It is reasonable to conclude that if family were able and willing to provide all the necessary care the patient needs when the PCA is not present, there would not be a request for 24 hour PCA services. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. The patient's ADL needs are extensive and it is medically necessary for caregiver support to be available 24 hours per day to assist with mobility, toileting/incontinence care, and repositioning during extended periods of time in bed. In the absence of voluntary caregivers who are able to provide the necessary care on a consistent basis, then PCA services are medically necessary to provide assistance for ADLs throughout the day and night.

Personal care aide services 24 hour live-in, 5 days per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for PCA services, 5 days per week, and 24 hours per day (live-in) is substantiated.  The insurer's denial is reversed.