Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, heart disease, chronic kidney disease (CKD) stage 3
Treatment: PCA (personal care aide) services 7 days per week 2-12 hours split shift (168 hours per week)
The insurer denied coverage for the PCA services 7 days per week 2-12 hours split shift (168 hours per week).
The denial is overturned.

This elderly female has substantial functional impairment associated with various medical conditions. The patient lives alone. One informal helper is identified in the Uniform Assessment System (UAS) report who provides some assistance, but the patient primarily depends on personal care aide (PCA) services for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient had been receiving PCA services 7 days per week 2 - 12 hour shifts per day (split shift). 

The patient has substantial physical and cognitive impairment which requires a high level of assistance to complete ADLs effectively and safely. The patient needs help with ADLs that occur at unscheduled and recurring times of the day and night. Based on available records, it appears the patient's need for ADL care over 24 hours occurs with frequency that is not compatible with live-in services (including nighttime incontinence care and repositioning). In addition, the patient's unpredictable behavior (nighttime agitation) requires attention from the aide. This is not safety supervision. When the patient become anxious/agitated, it is necessary for the aide to try to determine if the behavior may be due to pain or other care need (e.g., soiled diaper). At times, verbal re-assurance may help calm the patient. This may not conform to standard PCA responsibilities of ADL/IADL care but is often part of the total responsibility of caring for a person with dementia. However, frequent attention to the patient during the night limits sleep time for a live-in aide, who then must function all day after a night of inadequate sleep. Live-in services for a person with frequent ADL needs and unpredictable behavior does not serve the best interest of the aide or the person requiring care. If a live-in aide has inadequate sleep, the aide is at risk for personal health and safety problems; and places the patient at risk, as there is greater chance of errors (e.g., medication) and accidents during care if the aide does not have sufficient rest.

The patient needs assistance for all routine IADLs and ADLs; and for ADLs that occur at unscheduled and recurring times of the day and night (including toileting/incontinence care and bed mobility). It does not appear the patient's daily care needs can be met with live-in services, which includes 5 hours of uninterrupted sleep per day for the aide on a regular basis (plus 3 more hours of sleep at variable times during the day or night). Therefore, PCA 24 hours per day continuous services (split shift) are necessary.

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

The insurer's denial of coverage for the personal care aide (PCA) services 7 days per week 2-12 hours split shift (168 hours per week) is overturned. Medical Necessity is substantiated.