Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, osteoporosis, age-related physical disability and urinary incontinence

Treatment personal care aide (PCA) services of 7 hours per day, 6 days per week for a total of 42 hours per week

The insurer denied coverage for personal care aide (PCA) services of 7 hours per day, 6 days per week for a total of 42 hours per week

The denial is overturned

This patient has functional impairment affecting her ability to perform most daily activities. She lives with her son, and she has a daughter who lives out of state but visits often. The daughter's appeal letter indicated her mother's mental and physical condition have declined. The patient receives personal care aide (PCA) services 5 hours per day, 6 days per week. The daughter is concerned for her mother during the hours she is alone, between the departure of the aide and arrival home in the evening by the son (per daughter, the son returns home around 8pm (post meridiem), sometimes later). The daughter (as patient designee) requested increase of PCA services to 7 hours per day, 6 days per week, which was denied.

The patient's cognitive status is described from various sources. Uniform Assessment System (UAS) describes the patient's decision-making ability for daily tasks as modified independence. She was oriented to person, place and time, with no identified short term or procedural memory loss. She was self-directing and was able to describe an emergency plan. The patient does not remember to take medication without reminder. The patient reported to have declining memory due to Alzheimer's disease. It was noted MMSE (mini-mental state exam) was done, but result was not identified in the available records. In the UAS, description was similar, but the son reported patient has short term memory issue, she repeats questions multiple times; she eats multiple meals because she forgets she has already eaten. 

The need to use the toilet is an unplanned, recurring activity throughout the day. The aide is present only 5 hours per day, but the patient is probably alone for at least another 5 hours until her son returns (around 8pm or later as per daughter). The available records support the need for caregiver assistance for a more extended period of time each day to assist with toileting related care. 

The patient's son is the only informal caregiver on a regular basis (the daughter visits from out of town). He assists the patient in the evenings, but according to the daughter, he arrives home at 8pm or later, which leaves the patient alone for several hours. If the PCA schedule was changed and the aide arrived later (for example at noon), then the patient would be alone all morning with no assistance for all morning activities of daily living (ADLs), and the patient would still be alone for a few hours before her son arrives home. Considering the daughter is requesting PCA services 42 hours per week, 7 hours per day, 6 days per week, it is reasonable to conclude informal caregivers are unable to assist the patient for this amount of time each day (6 days per week) when the son is not home. 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 with ADLs and instrumental activities of daily living (IADLs) when needed. The patient will benefit from increase of PCA services to 
7 hours per day, 6 days 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 the requested Personal Care Aide (PCA) Services of 7 hours per day, 6 days per week for a total of 42 hours per week is overturned. Medical necessity is substantiated.