Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Physical and cognitive impairment.

Treatment: Personal Care Aide (PCA) Services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The insurer denied coverage for PCA Services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week.

The denial is overturned.

This is a female patient with diagnoses: dementia, diabetes mellitus type II, angina pectoris, hypertension, kidney insufficiency, osteoarthritis of hips, arthritis of fingers (both hands), spinal stenosis, lumbar radiculopathy, claudication, gait instability, and recurrent falls. Due to the patient's medical conditions and recurrent falls, it is recommended that the patient's Home Health Aide (HHA) hours are increased to 24 hours/7 days a week. This patient has substantial functional decline due to physical and cognitive impairment. As per the Uniform Assessment System (UAS) report, the patient lives alone. The patient's daughter requested an increase of Personal Care Aide (PCA) services to two 12 hour shifts per day x 7 days per week.

Based on UAS documentation, the patient's functional status for instrumental activities of daily living (IADLs) indicates total dependence for meal preparation, housekeeping tasks, shopping, finances; maximal assistance for medications, stairs, transportation; extensive assistance for phone use.  For activities of daily living (ADLs), the patient needs maximal assistance for bathing and lower body dressing; and extensive assistance for all other ADLs, except eating (supervision). Considering the patient's medical history and functional status it is medically necessary for her to have caregiver assistance throughout the day and night for all routine IADLs and ADLs; assistance for unscheduled ADLs (including transfers, walking, toileting/incontinence care); repositioning the patient periodically when she is bed for pressure relief, and when needed for pain relief. Without adequate caregiver assistance, the patient is at risk for adverse health and safety events.

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at various and unscheduled times through the day and night. As per NYS regulations for personal care services, 24 hour care can be provided as live-in services or continuous services. In order to qualify for a live-in aide, the patient's need for assistance should be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep in an 8 hour sleep period per day. If the patient's ADL needs are too frequent to allow for this amount of sleep for the aide, then continuous services (i.e. split shift) are necessary.  It is unlikely that an aide would reliably obtain 5 uninterrupted hours of sleep each night considering the patient's unpredictable behavior (i.e. attempting to get out of bed), unsafe mobility, and toileting/incontinence needs. It does not appear that a live-in aide is the best plan for the patient, as it either leaves the patient without assistance when the aide tries to sleep, or the aide is placed in a difficult situation of trying to sleep, knowing the patient may need assistance during the aide's sleep period. At this time, the prudent course of action is to implement continuous PCA services. 

The medical necessity 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 (split shift) for a total of 168 hours per week is substantiated.  The insurer's denial is overturned.