Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision loss; hearing loss; chronic pain
 
Treatment: Continuation of personal care aide (PCA) services 7 days per week 24 hours per day (live-in)

The insurer denied coverage for continuation of personal care aide (PCA) services 7 days per week 24 hours per day (live-in). The denial is reversed. 

This patient is a female who lives alone with assistance from personal care aide (PCA), 24 hours live-in. The patient has several medical conditions/symptoms that contribute to functional impairment, including: severely hearing impaired with mobility problems requiring weight-bearing assistance for walking, transfers, toileting; she cannot provide self-care for incontinence, she needs assistance with bed mobility, and cannot even obtain food or fluids without assistance.  

Considering the patient needs assistance for all ADLs it is not apparent how these activities would be effectively managed throughout the day with PCA services limited to 8 hours per day. All 3 meals would need to be completed when the aide is present, as the patient needs maximal assistance for meal preparation and extensive assistance for eating.  If a snack and fluids are left near her bed when the aide leaves, there is risk of spillage due to her inability to see the items. For evening tasks such as personal hygiene, change of clothes, getting into bed, the patient needs assistance; and so all these tasks would need to be done before the aide leaves each day.  The patient would then be in bed for 16 hours; unless she tries to get up unassisted, which places her at high risk for falls and accidents. There is also concern for the occurrence of pressure ulcers with such prolonged period of confinement to bed each day. 

The patient needs some assistance with bed mobility, and so it is uncertain whether the patient can reposition herself adequately in bed without assistance to prevent pressure ulcers.  With the realistic possibility of incontinence at night and patient remaining in wet, soiled diapers for extended periods of time, pressure ulcer risk is increased.  Another concern regarding bed mobility is whether the patient can adequately reposition herself without assistance if she has pain or discomfort due to her position in bed.

Neither the UAS nor the insurer's final determination letter provides clinical support for reduction of PCA services.  It is medically necessary and in the patient's best interest to have caregiver support throughout the day and night due to the need for assistance with ADLs, including those that occur at various and unscheduled times throughout the day and night (e.g. toileting, incontinence care, walking, transfers).  The patient has no identified informal caregivers who can provide care to the patient on a consistent basis for an extended period of time each day.  Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services.  Without reliable and adequate care from informal caregivers, then PCA services are medically necessary to provide assistance with ADLs that are needed throughout day and nighttime hours.

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

The carrier's denial of coverage for continuation of personal care aide (PCA) services 7 days per week 24 hours per day (live-in) is reversed.  The medical necessity is substantiated.