Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Cardiovascular disease, Chronic obstructive pulmonary disease, Dementia
Treatment: Personal Care Aide (PCA) services, 168 hours per week (split shift)

The insurer denied coverage for PCA services, 168 hours per week (split shift)
The denial is overturned. 

This is a female patient who has an extensive medical history and functional impairment. She lives alone and receives Personal Care Aide (PCA) services 10 hours per day, 70 hours per week. The patient's daughters have been staying with the patient overnight to provide assistance with nighttime care; but they cannot continue providing this care long term. The patient (via designee) requested an increase of PCA services to 24 hours per day split shift.

The most recent Uniform Assessment System (UAS) report provided for review was done telephonically. The patient's functional status report indicated she is totally dependent or needs maximal assistance for all instrumental activities of daily living (IADLs), except extensive assistance for phone use. For activities of daily living (ADLs), she is totally dependent for lower body dressing; needs extensive assistance for eating; and needs maximal assistance for all other ADLs. Her physician reported a diagnosis of dementia with deteriorating memory. The UAS reports decision making capacity as consistently poor or unsafe. With impaired memory and decision making capacity, it is likely the patient has impaired safety awareness, with increased risk of adverse safety events if she is alone. Her medical history includes various possible contributing factors to her impaired ability to perform daily activities. Her medical history includes osteoarthritis, cardiovascular disease, and chronic obstructive pulmonary disease (COPD). Considering the patient's medical history, symptoms, and functional status, it is medically necessary for the patient to have assistance for all daily activities. Without adequate caregiver support through the day and night, the patient is at risk for adverse medical and safety events.

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. Considering the family is requesting PCA services 24 hours per day split shift, it is reasonable to conclude that there are no informal caregivers who can provide care for extended periods of time on a regular basis each day. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at various and unscheduled times during the day and night. As per NYS regulations for personal care services, 24 hour care can be provided as live-in services or 24 hour continuous care, i.e. split shift.  In order to qualify for 24 hour live-in services, the patient's care needs 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 high frequency that the aide cannot have this amount of sleep on a regular basis, then continuous services are indicated. Based on the nighttime activity logs submitted by the patient's daughter, the patient needs assistance with ADLs at various and multiple times through the night. The time intervals between episodes of care provided by the patient's daughter for each of the 5 nights recorded does not include 5 uninterrupted hours when an aide could sleep each night. Earlier in the day or evening, household and personal care tasks are too frequent to allow a 5 hour sleep period for an aide. Therefore, continuous services (split shift) are necessary. 

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

The carrier's denial of coverage for PCA services, 168 hours per week (split shift) is overturned. The medical necessity is substantiated.