Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Advanced dementia, Parkinson's disease, Osteoarthritis, Chronic pain.
Treatment:  7 days x 24 hours (continuous [personal care] services).

The insurer denied coverage for 7 days x 24 hours (continuous [personal care] services).  The denial is overturned.

This is a male patient with a history of Alzheimer's disease, vascular dementia, Parkinson's disease, anxiety, depression, benign prostatic hyperplasia, edema, hypertension, hypokalemia, hypomagnesemia, hypercholesterolemia vitamin deficiency, coronary heart disease and other dementia.  The patient was previously approved for Personal Care Assistance (PCA) services 7 days x 10 hours per week.  The patient (via designee) requested PCA services, 7 days x 24 hours (continuous services), which was denied.  The insurer approved live-in services, which the family declined, opting for appeal of request for 24 hours continuous services.  The insurer approved PCA 84 hours per week. 

The functional status from the Uniform Assessment System (UAS) report indicated the patient was totally dependent or needs maximal assistance for all instrumental activities of daily living (IADLs).  For activities of daily living (ADLs), it was noted the patient is totally dependent for bathing and lower body dressing; and needs maximal or extensive assistance for all other ADLs.  The family reported the patient has difficulty following direction even when cueing is provided.  He gets agitated and resists care at times. Regarding the patient's cognitive status, the patient's physician indicates the patient has advanced dementia (Alzheimer's disease and vascular dementia).  It appears the patient has substantial cognitive impairment, with severely impaired decision making, extensive memory loss, confusion, easily distracted, disorganized speech.  The patient's cognitive impairment is most likely the primary cause of his functional impairment, but physical symptoms can exacerbate functional decline. 

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services.  The family declined live-in aide services, and requested PCA 24 hours continuous services.  It is reasonable to conclude that neither the patient's wife, nor any other informal caregivers can continue to provide assistance to the patient for extended periods of time on a daily basis.  When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide assistance for daily activities when needed throughout the day and night.
 
The patient needs assistance with transfers, walking, toileting/incontinence care due to loss of ability to perform these activities as a result of advanced dementia and chronic pain.  The patient needs assistance for all ADLs whenever they occur, and the records indicate the need for ADL assistance occurs multiple times throughout the night.  The assistance an aide provides to the patient when he needs to transfer, walk, use the toilet or needs incontinence care in the morning or afternoon, is the same as the assistance needed in the evening or the middle of the night.  Considering the frequency of the patient's need for ADL assistance during the day and night, the patient's care needs cannot be effectively managed with a live-in aide, as it does not appear that the aide can expect to have 5 uninterrupted hours of sleep per day on a regular basis.  Therefore, it is medically necessary for the patient to have personal care assistance 24 hours per day as continuous services to provide the patient with assistance for all daily activities, including ADLs that occur at various and unscheduled times throughout the day and night. 

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

The carrier's denial of coverage for 7 days x 24 hours (continuous [personal care] services) per week is overturned.  The medical necessity is substantiated.