Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease, Dementia

Treatment: Personal Care Aide (PCA) services 24 hours (split-shift) per day, 7 days per week

The insurer denied coverage for Personal Care Aide (PCA) services 24 hours (split-shift) per day, 7 days per week

The denial is overturned.

This patient has substantial functional impairment associated with several medical conditions and needs help with all daily activities. The patient lives alone. The records identify one informal caregiver, patient's daughter, who reportedly has limited ability to help the patient due to their own health issues. The patient primarily relies on personal care aide (PCA) services for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient was receiving PCA services 12 hours per day, 7 days per week. The daughter (as patient designee) requested PCA services 24 hours (split shift) per day, 7 days per week, which was denied; but the insurer increased services to PCA live-in, 7 days per week. External appeal was requested.

The most recent Uniform Assessment System (UAS) was provided for review. The functional status report for IADLs indicates patient was totally dependent for meal preparation, managing finances, ordinary housework, phone use, shopping, stairs.  The patient needed maximal assistance for transportation and extensive assistance for managing medications. For ADLs, walking and locomotion were reported as: activity did not occur during entire period. The patient needed maximal assistance for bathing, personal hygiene, dressing lower body, toilet transfer, toilet use; extensive assistance for dressing upper body, bed mobility, eating.

As per New York State (NYS) regulations for personal care services, 24-hour care can be provided as live-in services or continuous (split shift) services. For 24-hour live-in services, the patient's care needs over 24 hours must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8-hour sleep period each day. If the patient's care needs are of such frequency that the aide cannot have this amount of sleep on a regular basis, then continuous services are indicated (split shift). This review is to determine if the patient's daily care needs can be adequately met with live-in services; or if continuous services are necessary. The records provided for review do not include day/night activity logs, but the available information can help determine the type and frequency of the patient's daily care needs.

The sleep time for a live-in aide does not have to occur at night; but it appears unlikely an aide could sleep for 5 uninterrupted hours during the day. Even if meal preparation and household tasks are done at night, the aide needs to assist the patient during the day with all routine ADLs (bathing, dressing, personal hygiene) plus other tasks that require help at various times through the day and night.  

Based on the available information, the frequency of the patient's scheduled and unscheduled/recurring ADL/IADL care needs during the day and night does not appear compatible with PCA live-in services, which includes 5 uninterrupted hours of sleep for an aide on a regular daily basis. PCA 24-hour services, split shift is medically necessary to effectively and safely meet the patient's care needs day and night. 

Recommendation is given to approve Personal Care Aide services 24 hours (split shift) per day, 7 days per week.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Aide (PCA) services 24 hours (split-shift) per day, 7 days per week is substantiated.