Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD), hyperlipidemia, osteoarthritis (OA), macular degeneration, and malignant neoplasm of the skin.

Treatment: Increase in PCA (personal care aide) services to 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week.

The insurer denied coverage for an increase in PCA (personal care aide) services to 12 hours per day- 7 days per week: 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week.

The denial is overturned.

This female has significant functional impairment associated with several medical conditions and needs assistance with all daily activities. She lives alone; her sons visit weekly and provide some assistance, but she primarily depends on personal care aide (PCA) services to assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She had been receiving PCA services 7 hours per day, 7 days per week, total of 49 hours per week. The insurer's final denial letter includes appealer's comments that services were insufficient to address the patient's care needs. Request was made for PCA 24 hours per day split shift, which was denied; but PCA hours were increased to 8 hours per day, 7 days per week, total of 56 hours per week. An external appeal was requested. 

The most recent UAS (uniform assessment system) provided for review indicates patient is totally dependent or needs maximal assistance for all IADLs (independent activities of daily living). The patient needs maximal assistance for most ADLs; except eating (extensive assistance). 

It does not appear live-in aide services can adequately meet the patient's daily care needs. During the day/early evening hours, the aide assists with all routine morning and evening ADLs; meal preparation and service for all meals and assistance with eating; all housekeeping tasks; all toileting/incontinence care and mobility throughout the day and night. There does not appear to be a clear window of opportunity for a live-in aide to have 5 uninterrupted hours of sleep per day on a regular basis, especially considering the description of the patient's behavior and ADL needs (toileting/mobility) at night. If a live-in aide does not obtain sufficient sleep, the aide is at risk for personal health and safety problems; and places the patient at risk, as there is greater chance of mistakes and accidents if the aide is working with inadequate rest. The patient has limited assistance from informal helpers (per UAS, her sons provide a few hours of help once a week). Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance for daily activities, including ADLs that occur at various unscheduled and recurring times throughout the day and night. The available information supports medical necessity for 24 hours per day continuous personal care services, as described in this review; and there are no informal caregivers identified who can provide care for extended periods of time each day on a regular basis. 

Recommendation is given to approve Personal Care Aide Level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week. 

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

The insurer's denial of coverage for personal care aide (PCA) level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week is overturned. Medical Necessity is substantiated.