Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Alzheimer's Dementia

Treatment:  personal care assistant (PCA) services 7 days x 24 hours (live in services)

The insurer denied coverage for PCA services 7 days x 24 hours (live in services).

The denial is overturned.

This is a female patient with multiple medical conditions who lives alone. She receives personal care assistant (PCA) services 56 hours per week, 8 hours per day. A request was made for an increase of PCA services to 24 hour live-in. The patient is totally dependent for housework and shopping and requires maximal or extensive assistance for all other instrumental activities of daily living (IADLs) except phone use (setup help). She needs extensive or limited assistance for most activities of daily living (ADLs); except eating, bed mobility and personal hygiene, for which she needs independent setup help. 

The patient's physicians noted a decline in her functional status and an increased need for assistance with daily activities. She needs assistance with transfers, walking and toileting, and she is at high risk for falls. She has osteoarthritis and needs extensive assistance with bathing and lower body dressing. She has dyspnea with moderate activity, and fatigue to the extent that she is unable to finish daily activities. She also has chronic obstructive pulmonary disease (COPD). COPD in elderly people is associated with significant functional impairment, and may be a factor in the patient's increasing difficulty with daily activities. 

In the Uniform Assessment System (UAS), the patient was noted as very forgetful with some impairment of decision making capacity for daily tasks. The physician noted that her cognitive ability has declined and has affected her ability to perform her regular daily activities. She has Alzheimer's dementia and a history of depression. Dementia and depression often co-exist, and depression may exacerbate cognitive decline. When functional impairment is associated with dementia and/or mood disorder (e.g. depression) it is often necessary for a caregiver to provide supervision and/or assistance to help direct the person to properly perform ADLs. Information from UAS, physician letters, and activity logs supports the patient's need for assistance with all household related tasks and ADLs due to physical and cognitive impairment and mood disorder (depression). Therefore, it is medically necessary for the patient to have caregiver assistance throughout the day and night to ensure proper and safe performance of daily activities. 

The patient's children take turns staying with the patient during the hours when the PCA is not present; but they are unable to continue providing evening and nighttime assistance due to their other responsibilities. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. When informal caregivers are unable to provide assistance with daily activities on a regular basis, then personal care services are indicated to assist the patient with IADLs and ADLs when needed. It is not clear whether the patient's nighttime care needs would allow a live-in aide to have 5 uninterrupted hours of sleep per day, as required by NYS regulations for personal care services. The maximum number of hours that can be approved from this review is limited by the amount requested, i.e. 24 hour live-in.
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for PCA services 7 days x 24 hours (live in services) is substantiated. The insurer's denial is overturned.