Appeal type: Medical necessity
Decision: Overturned

Diagnosis: coronary heart disease, stroke, chronic fatigue, hypertension, full incontinence of feces, history of falling, hyperlipidemia, generalized muscle weakness

Treatment: Personal care aide (PCA) hours, two 12-hour split shifts per day, 7 days per week.

The insurer denied coverage for personal care aide (PCA) hours, two 12-hour split shifts per day, 7 days per week.

The denial is overturned.

This geriatric patient has significant physical and cognitive impairment associated with several medical conditions. The patient lives alone and needs assistance with all daily activities. The insurer's final denial letter includes report from the patient's daughter that a family friend had been staying with the patient at night but is no longer able to continue with this plan. The cardiologist's letter included a comment that the daughter has health problems that limit the ability to care for the patient. The patient receives personal care aide (PCA) services to assist with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). The plan previously approved PCA services 12 hours per day, 7 days per week. The daughter requested PCA services two 12-hour split shifts per day, 7 days per week, which was denied, but the insurer increased PCA services to live-in, 7 days per week. 

The most recent Uniform Assessment System (UAS) provided for review was reviewed. Functional status is reported as total dependence for most IADLs, except managing medications (maximal assistance). For ADLs, the patient is totally dependent for bathing, dressing lower body, toilet transfer, toilet use, and locomotion; the patient needs maximal assistance for personal hygiene, dressing upper body, bed mobility; and extensive assistance for eating. It was noted walking did not occur during entire period.

As per NYS (New York State) regulations for personal care services, 24-hour care can be provided as live-in services or continuous (split shift) services. In order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8-hour sleep period each day. If the patient's care needs are of such frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services are indicated, such as, split shift. The focus of this review is to determine whether the patient's daily care needs can be adequately met with live-in services; or if continuous services are necessary.

Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. When the patient needs incontinence care, or repositioning for pressure or pain relief, or if the patient tries to get up from bed and needs help with transfer or returning to bed; this is not safety supervision. The patient needs assistance for effective and safe completion of ADLs that are essential for health and comfort. These care needs must be considered in the determination of the patient's personal care service hours. 

As per the UAS, there are no informal helpers; and a family friend who was helping the patient at night can no longer provide this service. As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance when needed for daily activities, including ADLs that occur at unscheduled and recurring times through the day and night.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care aide (PCA) hours, two 12-hour split shifts per day, 7 days per week is substantiated.