Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, heart failure, atrial fibrillation, and osteoarthritis

Treatment:  PCA (personal care aide) level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The insurer denied coverage for PCA level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The denial is overturned.

This is the case of an adult female who has extensive medical history of progressive functional decline. The records provided for review indicate 4 recent hospitalizations and admission to Nursing Home (NH) for short term rehabilitation. At the time of the Uniform Assessment System (UAS), the patient was severely impaired physically and cognitively; reported in UAS as bedbound and required total care. The patient lives with her husband who also receives personal care aid (PCA) services (mutual case). It appears he is no longer able to provide activities of daily living (ADL) assistance to his wife, and there are no other informal caregivers identified in the UAS. The patient is dependent on PCA services for all her daily care needs. The patient had been receiving PCA services 45.5 hours per week (6.5 hours per day). The patient (via designee) requested increase of PCA services to 24 hours split shift, which was denied; but PCA services were increased to 10 hours per day, 70 hours per week. An external appeal was requested.

The patient has several medical conditions that can contribute to significant functional impairment and decline in ability to perform daily activities. The patient has extensive cardiac disease, including coronary artery disease, heart failure, atrial fibrillation. She had a stroke resulting in right-sided weakness. The physician's letter indicates patient has vascular dementia. The patient has osteoarthritis and degenerative disc disease (lumbar spine). The UAS noted the patient had pain in lower back, and upper and lower extremities; and UAS reports patient has limited range of motion. 

It is noted she is bedbound. She is totally incontinent, and dependent on caregivers for incontinence care. For a person who is completely incontinent and totally dependent for incontinence care, a caregiver needs to be available through the day and night, as incontinence occurs at various unplanned times of the day and night. Diapers are not the full solution. Remaining in wet soiled diapers for extended periods of time is inconsistent with medical and nursing standards of care for incontinence and skin care; and can result in incontinence associated skin damage (e.g., dermatitis, fungal infection); and is a source of discomfort for the patient. 

The patient has a supportive family; but the patient needs assistance beyond 70 hours per week, and there is insufficient informal caregiver assistance to meet the patient's daily care needs during non-PCA hours. As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. 

Based on the submitted documentation, Personal Care Aide (PCA) services Level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week are medically necessary. 

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 the requested Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (Split Shift) for a total of 168 hours is overturned. Medical necessity is substantiated.