Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Personal Care Assistance Services (two-12 hour split shift services)

The insurer denied the Personal Care Assistance Services (two-12 hour split shift services). The denial was reversed. 

This is an elderly female patient who was status post hospitalization for duodenal ulcers, no active bleeding with a blood transfusion.  The patient was discharged to a skilled nursing facility for short term rehabilitation.  She has a medical history of severe dementia, depression, hypertension, chronic kidney disease stage IV, asthma, heart failure with reduced ejection fraction 27%, coronary artery disease, a history of C. difficile, bladder cancer, status post cystectomy with ileal conduit. There is documentation by a nurse practitioner who provides house call services to patient indicating that the patient has severe dementia with behavioral disturbance (including wandering). She is at high risk for falls due to gait instability; she should not be left alone.  It is her recommendation that the patient have 24-hour home attendant services.

It is noted that the UAS from mid-2019 differs significantly from the UAS from later in 2019. The later 2019 UAS indicates that the patient needs maximal assistance for toilet use and extensive assistance with most other ADLs.  House call notes from the patient's medical provider indicate that the patient has gait instability and is at risk for falls; needs to be repositioned in bed every two hours to prevent pressure ulcers and is at risk for aspiration and needs to be positioned in bed to decrease the risk of aspiration. 

It appears that the patient's daughter who lives in New York is the patient's primary informal caregiver.  It was noted in the mid-2019 UAS that the daughter cannot continue to provide support to her mother due to other family and job responsibilities and distance from her mother.

As a result of her medical conditions (dementia, arthritis, ileal conduit), it is medically necessary for the patient to have caregiver assistance for ADLs during day and night hours.  As per NYS regulations for personal care services, assistance provided by informal caregivers is voluntary. In the absence of informal caregivers to provide care on a regular basis, then PCA services are indicated to provide the necessary assistance. 

Due to dementia, the patient's nighttime behavior may be unpredictable and per the UAS, she has a history of difficulty sleeping.  When she is awake at night, it is necessary for a caregiver to be awake in order to provide assistance when needed for out of bed activities (i.e. walking, transfers, toileting).  Even when the patient is in bed and asleep, the patient needs to be repositioned several times during the night, and the ostomy bag needs to be checked to prevent leakage.  It does not appear that an aide would usually be able to have five uninterrupted hours of sleep each night (as required for 24-hour live-in PCA aides per NYS regulations).  Therefore, it appears that PCA services, two 12 hour split shift, can better accommodate the patient's needs. 

Based on the above, the medical necessity for personal care assistance services (two-12 hour split shift services) is substantiated. The insurer's denial is reversed.