Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, Osteoarthritis

Treatment: Personal Care Aide (PCA) Level 2: 24 hours per day split shift

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 24 hours per day split shift. 

The denial is overturned. 

This is a female with diagnoses: Alzheimer's dementia, depression, hypertension, diabetes mellitus II, osteoporosis, orthostatic hypotension, chronic headaches, vertigo, muscle weakness, fatigue, shortness of breath, insomnia with sleep-wake cycle disturbance, osteoarthritis, chronic pain, lumbar degenerative disc disease, diabetic peripheral neuropathy, diabetic retinopathy, hearing loss, urinary and fecal incontinence, and history of falls. The patient has limited range of motion and mobility. The patient is unable to walk without human assistance. The patient is incontinent and requires multiple day and nighttime changing of soiled diapers to prevent skin rash. The patient needs continuous supervision and assistance with activities of daily living (ADLs). A request was made to increase Personal Care Aide (PCA) services to 24 hours split shift, which was denied by the insurer.

The Uniform Assessment System (UAS) report indicates that the patient is totally dependent or needs maximal assistance for all instrumental activities of daily living (IADLs). The patient needs maximal assistance for all ADLs, except bed mobility and eating (extensive assistance). There was some decline in ADLs function since the previous UAS report. A few changes included: walking and toilet transfer declined from extensive to maximal assistance; and bed mobility and eating declined from limited to extensive assistance. Based on information from the UAS report and physician, it appears the patient's cognitive impairment is a significant factor of loss of ability to perform IADLs, in addition to her physical impairments which also most likely interfere with performance of some IADLs, such as household related tasks and stairs.

Without a detailed record of the patient's day/night ADLs, the determination for PCA services as live-in versus split shift must be based on the patient's medical history, functional status, reasonable expectation of the frequency of need for assistance with ADLs, and risk of adverse medical/safety events if assistance with ADLs is delayed for a period of several hours. Remaining in wet, soiled diapers for several hours can increase risk of skin damage, and is a source of discomfort for the patient. Delay in assisting the patient if she tries to get up from bed is associated with high risk of fall and injury. Remaining in one position for several hours can increase risk of pressure injury and may cause pain/discomfort to back or extremities. Delay in providing assistance for these ADLs during the day or night can result in significant adverse outcomes. In order to provide care promptly when needed through the night, it does not appear that an aide would be able to consistently have 5 uninterrupted hours of sleep every night. Therefore, it is medically necessary and in the patient's best interest to provide PCA services as 24 hours spilt shift.

Assistance from informal caregivers is voluntary as per the New York State regulations for personal care services. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed. When re-assessment is done, a more detailed description of the patient's nighttime activity would be helpful to determine the need to continue split shift services at that time. 

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 requested PCA Level 2: 24 hours per day split shift should be overturned. The medical necessity is substantiated.