Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, coronary artery disease, type 2 diabetes mellitus, chronic obstructive pulmonary disease

Treatment: increase in PCA (personal care assistant) services to 12 hours per day- 7 days per week split shift- a total of 168 hours per week, as not medically necessary

The insurer denied coverage for increase in PCA (personal care assistant) services to 12 hours per day- 7 days per week split shift- a total of 168 hours per week, as not medically necessary

The denial is overturned

This patient has significant functional impairment associated with various medical conditions and needs assistance with all daily activities. He lives alone. His daughter and son are informal caregivers, but it appears they are unable to provide routine assistance with daily activities. The patient relies primarily on personal care assistant (PCA) services. The insurer's final adverse determination (FAD) indicates plan approval for PCA 70 hours per week (10 hours per day). The patient (via designee) requested PCA services to 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week, which was denied. External appeal was requested.

The most recent UAS (Uniform Assessment System) provided for review was done. The functional status report for IADLs (Instrumental Activities of Daily Living) indicates patient is totally dependent for housework; he needs maximal assistance for meal preparation, shopping, stairs, managing finances; extensive assistance for managing medications, transportation, phone use: extensive assistance. For ADLs, he needs maximal assistance for bathing, dressing lower body, walking, locomotion, transfer toilet, bed mobility; extensive assistance for personal hygiene, dressing upper body, toilet use; limited assistance for eating.

Falls in older people are associated with higher risk of serious injuries (e.g., fractures, head trauma), substantial morbidity, and increased risk of death. There are few, if any interventions that can prevent all falls, but when a person is identified as high risk for falls, it is necessary to implement a plan to help decrease occurrence of falls. Assistance for mobility-related ADLs (Activities of Daily Living) (e.g., transfers, walking, toileting) provides stability and physical support to facilitate safe mobility.

The available records do not identify any informal helpers who can provide care for extended periods of time on a regular basis. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance for daily activities, including ADLs that occur at various unscheduled and recurring times throughout the day and night.

Based on the patient's care needs as described in the available records, PCA services 70 hours per week and live-in services (which the patient is currently receiving) are not compatible with a safe, effective plan of care for the patient. The information provided for review supports the need for PCA 24 hours per day continuous services, split shift.

Recommendation is given to approve Personal Care Assistant services 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week.

The insurer's denial of coverage for an increase in PCA (personal care assistant) services to 12 hours per day- 7 days per week split shift- a total of 168 hours per week is overturned. Medical Necessity is substantiated.