Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, Osteoarthritis (OA), Major depressive disorder (MDD).
Treatment: Personal Care Assistance (PCA), Level 2 services, 24 hours per day, 7 days per week (live-in).
The insurer denied coverage for Personal Care Assistance (PCA), Level 2 services, 24 hours per day, 7 days per week (live-in). The denial is overturned.

This is a female with a medical history of Alzheimer's disease, osteoarthritis (OA), major depressive disorder (MDD), asthma and colostomy. She has substantial functional impairment and needs caregiver assistance for all daily activities. The patient lives alone. She is receiving personal care assistance (PCA) services 56 hours per week. The patient's daughter is the primary informal caregiver, but she can provide only limited assistance due to her work and other responsibilities. The patient (via designee) requested an increase of PCA services to 24 hours per day, live-in. The insurer denied live-in services, but increased the previously approved PCA services 42 hours per week to PCA services 56 hours per week.

The functional status reported in the Uniform Assessment System (UAS) report indicates that the patient is totally dependent on caregivers for all instrumental activities of daily living (IADLs), except managing medications and phone use (maximal assistance). The patient needs maximal or extensive (weight-bearing) assistance for all activities of daily living (ADLs) except bed mobility and eating (limited assistance). The patient's physician describes the patient's stage of Alzheimer's disease as moderate to severe. The UAS indicates the patient consistently makes poor/unsafe decisions for daily activities and needs cues and supervision at all times. Her short term and procedural memory is impaired. 

Considering the patient's medical history and substantial functional impairment, it is medically necessary to have a caregiver present to provide assistance to the patient for all scheduled tasks and ADLs that occur at unscheduled times during the day and night. She also needs repositioning on a regular basis for pressure relief. This level of care requires a caregiver to be present in the patient's home through the day and night. The UAS indicates that the patient has an informal caregiver (daughter); but the type and frequency of assistance provided appears limited. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. The request for increase of PCA services is for 24 hours live-in. With request for 24 hour care, it is reasonable to conclude that there are no informal caregivers who can provide assistance on a regular basis. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide the patient with assistance for all necessary daily activities when needed. As per NYS regulations for live-in aide services, the patient's need for assistance should be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep per day. If the patient's ADLs needs are too frequent to allow for this amount of sleep for the aide, then continuous services are indicated. The records provided for review support the patient's need for ADLs assistance at various times throughout the day and night. It is medically necessary and in the patient's best interest to approve the request for increase of PCA services to 24 hours live-in, as the patient is at risk for harm if she continues to be alone for extended periods of time. When live-in services are in place, the frequency of the patient's ADLs needs at night can be clarified, and the plan can be modified if needed. 

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

Based on the above, the medical necessity for PCA, Level 2 services, 24 hours per day, 7 days per week (live-in) is substantiated. The insurer's denial is overturned.