Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia; Diabetes mellitus.

Treatment: Increase in Consumer Direct Personal Aide Service (CDPAS) to 7 days x 12 hours.

The insurer denied coverage for increase in Consumer Direct Personal Aide Service (CDPAS) to 7 days x 12 hours.

The denial is overturned.

This female patient has diabetes mellitus with neurological manifestations, diabetic polyneuropathy, Alzheimer's dementia, and osteoarthritis. According to a Uniform Assessment System (UAS), the patient lived alone in a 1 bedroom apartment on the 4th floor with elevator accessibility. The patient's functional status included total dependence for meals, housework, and shopping. The UAS also noted that the patient needed assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

When the aide leaves, the patient does not eat until the next day (3pm-9am). This can result in weight loss and nutritional impairment. It is doubtful she takes adequate fluids and has risk for dehydration. No food intake after 3pm is a concern because the patient takes a sulfonylurea, which is associated with higher risk of hypoglycemia. It is uncertain whether the patient can identify symptoms of hypoglycemia and properly provide self-treatment. The patient needs maximal assistance for lower body dressing and extensive assistance for personal hygiene. 

Considering the extent of the patient's physical and cognitive impairment, it is medically necessary for the patient to have caregiver assistance to help prevent adverse health and safety events (e.g. falls, skin injury, malnutrition, dehydration, hypoglycemia). The patient needs assistance with activities that occur at various and unscheduled times throughout the day and night, including transfers, walking, toileting and incontinence care. She needs a caregiver present in the evening to ensure she has a meal and adequate fluids. The patient needs weight-bearing assistance to safely transfer and walk and so getting out of bed during the night unassisted is not safe, and increases her risk for falls.

The daughter has indicated she is the only informal caregiver and due to distance and her other family responsibilities she is not available on a daily basis for extended periods of time to help her mother. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. When informal caregivers are unable to provide the necessary assistance, then personal care services are indicated to provide assistance when needed for daily activities, including ADLs that occur at various and unpredictable times throughout the day and night.

Based on the information provided for review, the patient needs additional assistance for ADLs beyond the currently approved PCA services for 6.5 hours per day. PCA services 12 hours per day, 7 days per week would provide additional help through evening hours and can improve the patient's food and fluid intake, allow for proper administration time for late day medications, and provide assistance with mobility (walking, transfers) and toileting/incontinence care through early-mid evening.  The patient also needs assistance with toileting (including transfers/walking) and/or incontinence care for the other 12 hours of the night.

Personal Care Aide Level 2: 12 hours per day, 7 days per week; total of 84 hours per week are 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 an increase in Personal Care Aide Level 2: 12 hours per day -7 day (s) per week-a total of 84 hours per week is substantiated.  The insurer's denial is overturned.