Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral infarction and related diagnosis of acute embolism and thrombosis, pulmonary embolism

Treatment personal care assistance (PCA) services of 24 hours per day, 7 days per week (split shift)

The insurer denied coverage for personal care assistance (PCA) services of 24 hours per day, 7 days per week (split shift)

The denial is overturned

This is a patient of advanced age with a diagnosis of a cerebral infarction and related diagnosis of acute embolism and thrombosis, pulmonary embolism, peripheral vascular disease, chronic kidney disease, chronic vascular disorders of the intestine, cerebrovascular disease, dysphagia and hypertension. She also has unrelated diagnoses of asthma, diabetes mellitus, hyperlipidemia, gastroesophageal reflux disease and unspecified malignant neoplasm of the skin. The patient is under the care of Visiting Nurse Service of New York Hospice and Palliative Care. At issue is the necessity of 24 hour/7 day a week split shift personal care services.

The patient's functional ability for almost all daily activities declined. Most notable was the decline of activities of daily living (ADL) from limited or extensive assistance to maximal assistance (except eating, which declined from limited to extensive assistance). Mobility and toileting were the most significant change; as locomotion, transfer toilet, toilet use, bed mobility all declined from limited to maximal assistance. Walking was noted as limited assistance in the past, but now, the patient no longer walked. 

The patient is at high risk for pressure ulcers due to several factors including: incontinence, severely impaired mobility, and possible nutritional impairment (poor appetite, needs encouragement to eat, weight loss). The UAS indicates the patient is dependent on caregivers for all mobility, including bed mobility (max assist); and so it is necessary to have a caregiver present to reposition the patient on a regular basis throughout the day and night (in bed, and out of bed in chair/wheelchair). If the patient has a pressure relief mattress on her bed, this is useful; but repositioning is still necessary for a person who is high risk for pressure ulcers in order to fully remove pressure from an area of the body. The UAS indicates a turning and positioning plan is in place. Standard practice for pressure ulcer prevention generally includes repositioning every two hours, though this can vary with certain circumstances. The physician letters, hospice records, and the UAS nurse all indicate repositioning should occur every 2 hours. Even with some variability, repositioning should not be as infrequent as 5 hours. The night logs indicate repositioning occurred 5-6 times within a 12-hour period. Because the patient needs other types of assistance, turning and positioning is part of other types of care (e.g. during incontinence care) and then the patient can be placed in a different position when the task is done. 

The daughter and son are no longer able to provide informal care due to their other responsibilities. Assistance from informal caregivers is voluntary as per 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 assistance for daily activities when necessary throughout the day and night. 

Based on information from the UAS, medical providers, the family, and night activity logs, the patient's need for assistance with ADLs and instrumental activities of daily living (IADLs) cannot be adequately met within the hours of service provided by a live-in aide. A live-in aide will not be able to have 5 uninterrupted hours of sleep each day in an 8 hour sleep period on a regular basis. 

Therefore, 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 requested Personal Care Assistance (PCA) Services of 24 hours per day, 7 days per week (split shift) is reversed. Medical necessity is substantiated.