Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe dementia and extensive physical impairments.

Treatment: Personal Care Aide (PCA) Level 2 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 Level 2 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 who has a past medical history of an abdominal aortic aneurysm, coronary artery disease, dementia, diverticulosis, osteoarthritis, syncope, anemia, hypertension, hyperlipidemia and coronavirus disease 2019 (COVID-19). Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, her daughter and personal care aide were present on the call. The patient lives alone in a one bedroom apartment on the first floor of a two family home. The daughter reported that the patient is never left alone, and the family takes turns staying with her.  The patient is bed bound. She was hospitalized for weakness and fatigue related to COVID-19. She was discharged to a skilled nursing facility where she stayed until 3 days prior to the UAS date of completion. The patient has declined in overall self-sufficiency due to her hospitalization and stay in a skilled nursing facility. She also had a fall while in the skilled nursing facility. The patient was evaluated by staff but had no injuries. 

Needs are: 

1) Total dependence for meal preparation, ordinary housework, managing finances, managing medications, phone use, managing stairs, shopping, transportation, bathing, personal hygiene, dressing her upper and lower body, walking, locomotion, toilet transfer and toilet use;
2) Maximal assistance for bed mobility;
3) Extensive Assistance for eating;
4) Cognition: 	There is severe impairment. 
5) Continence: 	There is urinary and bowel incontinence. She uses diapers.

The patient's daughter is supportive and involved in all her care, but she has difficulty caring for her mother because she is legally blind. An increase to personal care aide (PCA) level 2 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 being requested.

The insurer has denied coverage for the PCA level 2 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 approved 10.5 hours per day, 7 days per week for a total of 73.5 hours per week. 

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

The patient has severe dementia. She has extensive physical impairments and needs at maximal assist or is totally dependent for all functions. 

The patient has bowel and bladder incontinence and is unable cognitively or physically to manage this, either in getting to the bathroom, cleaning herself, changing diaper, and positioning in bed.  These are 24-hour, unscheduled needs. 

The provision of diapers and durable medical equipment (DME) such as alternate pressure beds is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" in https://www.ncbi.nlm.nih.gov/books6430/ changing diapers regularly and positioning are also necessary.

Her daughter is an informal caregiver not able to tend to the necessary tasks.

The insurer's denial of coverage for PCA Level 2 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 overturned. Medical Necessity is substantiated.