Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's disease, Depression, Osteoarthritis.
Treatment:  Personal Care Aide (PCA) Level 2 services, 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift); total of 168 hours per week.

The insurer denied coverage for Personal Care Aide (PCA) Level 2 services, 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift); total of 168 hours per week.  The denial is overturned.

This is a female patient with substantial functional impairment associated with several medical conditions.  She requires caregiver assistance with almost all daily activities.  The patient lives alone.  She is currently approved for personal care aide (PCA) services 7 hours per day, 49 hours per week.  The patient (via designee) requested increase of PCA services to 24 hours split shift, which was denied.  

The functional status report in the Uniform Assessment System (UAS) report indicates the patient is totally dependent in household related activities and finances; she needs maximal or extensive assistance for all other instrumental activities of daily living (IADLs).  The patient needs maximal or extensive assistance for all activities of daily living (ADLs), except eating (independent setup help).  The patient's records identify some medical conditions and symptoms that probably contribute to her functional impairment and limited ability to perform daily activities including Alzheimer's disease, depression, osteoarthritis.  Considering the patient's medical history and extensive 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.  It is clear the patient's need for additional PCA hours through the day and night is not stand-alone safety supervision.  With the approved 7 PCA hours, the patient still needs substantial assistance to serve her dinner and prepare her for bed, which extends beyond 7 hours per day.  These routine tasks may be completed by early evening; but then the patient needs assistance for all toileting/incontinence care, out of bed mobility (walking, transfers) and bed mobility (repositioning) through the evening/night.  Assistance with ADLs is not stand-alone safety supervision. 

The patient has two informal caregivers, who were actively involved in her care but can no longer provide support.  Assistance from informal caregivers is voluntary, as per New York State (NYS) regulations for personal care services.  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 during the day and night.  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 in an 8 hour sleep period per day.  If the patient's ADL needs are too frequent to allow for this amount of sleep for the aide, then continuous services are necessary.  Without an actual assessment of the frequency of the patient's care needs, but with realistic indications for nighttime ADL assistance, the prudent choice is to initiate services that will minimize risk to the patient's health and safety, i.e., 24 hours continuous services (split shift) to ensure timely care when needed through the day and night.  When continuous services are in place, the frequency of the patient's ADL 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, and in the best interest of the patient.

The carrier's denial of coverage for PCA Level 2 services, 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split-shift); total of 168 hours per week is overturned.  The medical necessity is substantiated.