Appeal type: Medical necessity
Decision: Overturned

Diagnosis: anxiety, depression, age-related cognitive decline, vertigo, hypertension, Parkinson's disease, gastroesophageal reflux disease, hypothyroidism.

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

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

The denial is overturned.

This female has functional impairment associated with various medical conditions and needs assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient is approved for PCA services 7 hours per day, 7 days per week. The patient's daughter requested increase of services to 24 hours per day split shift, which was denied. 

The patient needs extensive assistance with toileting related tasks. Considering her difficulty with mobility (back and lower extremity pain, unsteady gait, dizziness, shortness of breath), the first obstacle is getting to the toilet or commode. She needs weight-bearing assistance with transfers and walking to reach the bathroom or commode; and then weight-bearing assistance to transfer on/off the toilet/commode. She also needs extensive assistance with toilet use. This may be at least partly due to pain in her shoulder limiting her ability for cleaning/hygiene. She probably also needs assistance with clothing adjustment (she needs maximal assistance with lower body dressing). The patient has frequent urinary incontinence. The cause is not noted, however, considering the patient's impaired mobility, it is likely that delay in reaching the toilet or commode is a significant factor causing urinary incontinence (i.e., functional incontinence) during the day and night. Considering the patient needs extensive or maximal assistance for related tasks, such as toileting and lower body dressing, it is likely that she needs substantial assistance with incontinence care. If the patient does not have adequate incontinence care, she is at risk for incontinence associated skin damage (e.g., dermatitis, fungal infection) due to prolonged exposure to wet soiled clothing and/or incontinence product. Incontinence is also a risk factor for falls. When a person with impaired mobility tries to reach a toilet quickly (to try to prevent incontinence), falls can occur due to inattention to safety when rushing to the toilet/commode. If there is leakage of urine on the floor from incontinence, this can cause a slip and fall accident. 

Managed Long Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. All the patient's care needs that occur throughout the day and evening/night must be considered in the determination of the patient's personal care service hours. The patient needs assistance for ADLs that occur throughout the day and night; and so additional service hours are not for stand-alone safety supervision.

The information provided for review supports the need for a caregiver to be present and awake during the day and night, to assist the patient with ADLs that occur at various and recurring times of the day and night, as previously described in this report. At this time, it does not seem prudent to have a 24 hour live-in aide as the caregiver. A live-in aide needs to have 8 hours of sleep per day, including 5 uninterrupted hours of sleep (as per New York State (NYS) regulations for live-in aides). The plan that would best serve the patient's needs is PCA 24 hours per day, split shift services.

The patient's children provide informal support, but considering the request is for 24 hour split shift services, it is reasonable to conclude that they are unable to provide care for extended periods of time each day on a regular basis.  Assistance from informal caregivers is voluntary as per NYS 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 when needed for daily activities, including ADLs that occur at various unscheduled and recuring times throughout the day and night.

Personal Care Aide (PCA) services 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 is medically necessary. The health plan did not act reasonably with sound medical judgment.

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week for a total of 168 hours per week split shift is overturned. Medical Necessity is substantiated.