Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease.
Treatment: PCA level 2 services of 21 hours per day, 5 days per week for a total of 105 hours.
The insurer is denied coverage for PCA level 2 services of 21 hours per day, 5 days per week for a total of 105 hours.
The denial is overturned. 

This female patient has a history of Alzheimer's Disease, hypertension, gastroesophageal reflux disease (GERD), osteoarthritis, urinary incontinence, and vitamin deficiency.

This is not a stand-alone safety monitoring issue. The patient needs maximal assistance for toileting related care, and so nighttime caregiver assistance is necessary for ADL care, with the additional burden on the caregiver of cleaning and sanitizing the area of the house where the incident occurs. MLTC (managed long term care) 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. The patient's toileting needs occur at various unpredictable times of the day and night. These care needs must be considered in the determination of the patient's personal care service hours. 

Considering the patient's high level of assistance needed for toileting, and the unpredictable timing throughout the day and night, it is medically necessary to have a caregiver with the patient through the day and night to assist the patient to the toilet and provide proper toileting care, including incontinence care when necessary. The caregiver can help decrease episodes of inappropriate toileting behavior if the patient is regularly assisted to the toilet, which can help decrease the patient's urge for bladder and bowel elimination when she is not on the toilet.

The daughter is requesting PCA (personal care assistant) services 21 hours per day, 5 days per week. The family is still able and willing to provide care for the patient on weekends. It appears the family is also able to provide care for 3 hours per day on weekdays, which may be the hours after work and before the family goes to sleep for the night (the daughter's note in the external appeal application specifically indicated the additional hours were needed for the night). 

As per 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 (activities of daily living) that occur at various unscheduled and recuring times throughout the day and night. The family is requesting 21 hours of PCA services per day on weekdays, with assistance provided by the family for the other 3 hours of the day on weekdays, plus full assistance on weekends. This plan is consistent with NYS regulations for personal care services and MLTC policy 16.07.  

Based on the submitted documentation, PCA Level 2: 21 hours per day, 5 days per week for a total of 105 hours per week are medically necessary.
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the PCA level 2 services of 21 hours per day, 5 days per week for a total of 105 hours is overturned.  The medical necessity is substantiated.