Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment is home care/ personal care HHC - personal care aide (PCA) 24 hours per day split shift
The insurer denied coverage for home care/ personal care HHC - personal care aide (PCA) 24 hours per day split shift
 The denial is overturned

This patient has frontotemporal dementia with progressive cognitive decline. She depends on caregivers for all daily activities. The patient lives alone. Her daughter provides some informal help, but the patient primarily depends on personal care aide (PCA) services for assistance with all IADLs (instrumental activities of daily living) and ADLs (activities of daily living). She has been receiving PCA live-in services. Her daughter (as patient designee) requested an increase of PCA services to 24 hours per day split shift, which was denied. An external appeal is requested by patient advocate as patient designee. 

The most recent UAS (uniform assessment system) provided was reviewed. The functional status report indicates the patient is totally dependent on a caregiver for all IADLs. For ADLs, it was noted the patient no longer walks (bedbound) and is totally dependent for most other ADLs; except maximal assistance for transfer toilet, bed mobility and eating. This assessment indicates further decline of ADL function compared to the previous UAS. ADL assessment indicated the patient needed maximal or extensive assistance for most ADLs; except for walking and locomotion she needed only limited assistance.

Based on the information provided for review, it is medically necessary for the patient to have a caregiver present who is awake and available to provide care promptly when needed throughout the day and night. This is necessary to ensure proper and safe completion of ADLs for this patient who is dependent on caregiver assistance for all daily activities. Providing this level and frequency of care is necessary to help prevent some potentially serious medical complications such as recurrent urinary tract infection; skin damage due to incontinence and pressure; dehydration. Intervention from the caregiver at night can also help alleviate some of the patient's anxiety/agitation and help her sleep.

The UAS identifies the daughter as the only informal helper. The UAS indicates the daughter visits a few times a week to check on her mother, but she also has other family responsibilities. As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed throughout the day and night. 

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 incontinence care, bed mobility). It does not appear the patient's daily care needs are compatible with the schedule of a live-in aide, which includes 5 hours of uninterrupted sleep per day on a regular basis (plus 3 more hours of sleep at variable times during the day or night). Therefore, personal care aide 24 hours per day continuous services (split shift) are necessary.

Recommendation is given to approve Home Care/Personal Care HHC - Personal Care Aide 24 hours per day (split shift).

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 home care/ personal care HHC - personal care aide (PCA) 24 hours per day split shift is overturned. Medical Necessity is substantiated.