Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, urinary incontinence, polyosteoarthritis, dementia, and gait and mobility abnormality

Treatment: Increase in personal care assistant (PCA) services from 7 days x 12 hours (84 hours) per week to continuous care split shift

The insurer denied coverage for an increase in personal care assistant (PCA) services from 7 days x 12 hours (84 hours) per week to continuous care split shift
The denial is overturned

This female has functional impairment associated with several medical conditions and needs assistance with all daily activities. The patient has primarily relied on personal care assistant (PCA) services to assist with ADL (activities of daily living) and IADL (instrumental activities of daily living). She had been receiving PCA services 84 hours per week. The patient requested (via designee) an increase of PCA services to continuous care split shift 7 days per week, which was denied: but the insurer increased services to live-in, 7 days per week. The advocate reported the family does not feel this is safe and the patient's daughter is temporarily staying with the patient; but the advocate noted the daughter is also elderly, and she cannot continue this arrangement. An external appeal was requested.

The most recent UAS (uniform assessment system) provided was reviewed and the patient's functional status report for IADLs indicated the patient is totally dependent for meal preparation, ordinary housework, shopping, and transportation; she needs maximal assistance for managing finances, stairs; extensive assistance for managing medications, and phone use. For ADLs, the patient needs maximal assistance for bathing, dressing lower body; extensive assistance for dressing upper body, walking, locomotion, transfer toilet, toilet use; limited assistance for personal hygiene; supervision for eating; and set up help for bed mobility.

Functional decline in older people is often the result of cumulative effects of multiple medical conditions affecting physical and/or cognitive function. Other contributing factors include economic and social circumstances, e.g., caregiver support.

The patient's cognitive status as reported in the UAS indicates decision making for daily tasks is minimally impaired (in some situations decisions are poor/unsafe). The patient was oriented x 2; she had short term memory impairment. Communication for expression and comprehension was noted as clear. The UAS and medical provider's note indicate the patient has a diagnosis of dementia. The available information does not include a detailed cognitive assessment, and so it is unclear to what extent the patient's cognitive impairment affects her daily activities. Memory impairment, and impaired judgment may affect safety during performance of daily activities. 

As per NYS (New York State) regulations for personal care services, 24-hour care can be provided as live-in services or continuous (split shift) services. 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 frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services are indicated, i.e., split shift. The issue to be determined in this review is whether the patient's ADL needs can be adequately met with live-in services or if continuous (split shift) services are necessary.

Recommendation is given to approve Personal Care Assistant services continuous care split shift, 7 days per week.

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 increase in personal care assistant (PCA) services from 7 days x 12 hours (84 hours) per week to continuous care split shift is overturned. Medical Necessity is substantiated.