Appeal type: Medical necessity
Decision: Overturned

Diagnosis: strokes-left hemiparesis; vascular dementia; wheelchair bound

Treatment: Personal Care Aide (PCA) Level 2: Live-In per diem: 24 hours per day, 7 days per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: Live-In per diem: 24 hours per day, 7 days per week. The denial was reversed.

This patient is a female who was  currently living in her daughter's apartment with 63 hours PCA services per week, All other care after the aide leaves is provided by daughter and granddaughter. The patient is severely disabled. She had strokes, resulting in left sided weakness/paralysis, and vascular dementia (significant cognitive impairment, poor decision making capacity). Other problems likely due to the patient's strokes include dysphagia, dysarthria, and incontinence. The patient is underweight, needs to be fed, and takes supplements.  She is at risk for aspiration. IADL and ADL level of care is either total dependence or maximal assistance.

It is evident that the patient needs care throughout the day and night. The insurer's final denial letter indicated that the UAS did not support the need for night time hours. In fact, the UAS provided substantial support for 24 hour care. The patient needs a caregiver for incontinence care which can occur at any time. She needs repositioning throughout the day and night. The patient is at high risk for pressure ulcers with risk factors including incontinence of bladder and bowel, underweight/nutritionally at risk, immobility. Chronic moisture from incontinence can result in incontinence associated dermatitis and increase risk of pressure ulcers. It is necessary to implement preventive measures for skin injury, as skin wounds for this patient could result in substantial morbidity; i.e. pain, infection, healing could be slow and difficult due to compromised nutritional status and diabetes. 

The patient cannot take food or fluid without assistance; and so if she is alone for extended periods of time, she is unable to eat or drink during that time.  Patient also is at risk for aspiration and has difficulty clearing secretions at times, so proper positioning in bed is needed to decrease risk of aspiration. The patient has contractures and weakness/paralysis of her left side. For general comfort, it is necessary to reposition the patient when she has pain or other discomfort due to immobility. She periodically has pain in her back and legs. Whether she needs medication or massage (as noted in the UAS) for pain management, she has no access to pain relief when she is alone.

The reason the patient has been able to manage with PCA services 9 hours per day is because she currently has her daughter and granddaughter to provide care for the rest of the day/night. As described in the physician's letter, this is not a permanent arrangement. The patient has an apartment secured but cannot move until proper home care services are in place. The location of the apartment is not close enough to her family for them to continue the level of care the patient requires when the aide is not present. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. It is apparent that the family has been able and willing to provide care to the patient; but it appears that this arrangement cannot continue indefinitely for the reasons noted. The patient's health and safety would be at risk (as noted above) if she is alone for extended periods of time in her home.

Personal Care Aide Level 2: Live-in per diem, 24 hours per day, 7 days per week is medically necessary. The health plan did not act reasonably in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Aide (PCA) Level 2: Live-In per diem: 24 hours per day, 7 days per week is substantiated.  The insurer's denial is reversed.