Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, congestive heart failure (CHF), gout, diabetes, postural hypotension, and degenerative disc disease
Treatment: 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 per week
The insurer denied coverage for 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 per week
The denial is overturned

This female has extensive medical history associated with substantial functional impairment. The patient lives alone. Her daughter provides some informal help, but the patient depends primarily on PCA services for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She had been receiving PCA services 70 hours per week. A request was made for increase of PCA services to 24 hours per day, split shift (two 12 hour shifts), which was denied. On appeal, the denial for 24 hours split shift services was upheld; but PCA services were increased to 24 hours per day, live-in services. 

The most recent Uniform Assessment System (UAS) provided wase reviewed. The functional status report for IADLs indicated patient is totally dependent for meal preparation, ordinary housework, managing finances, shopping, transportation; she needs maximal assistance for managing medications, phone use, stairs, equipment management. For ADLs, the patient is totally dependent for bathing, personal hygiene, dressing upper and lower body, toilet use; she needs maximal assistance for walking, locomotion, transfer toilet, bed mobility, eating.

As per New York State (NYS) 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, such as, split shift. 

Managed Long-Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. When the patient needs toileting/incontinence care; repositioning; possibly out of bed mobility (if the latter still occurs) this is not stand-alone safety supervision. Assistance is needed for effective, safe completion of ADLs which is essential for the patient's health and comfort and must be considered in the determination of her personal care services. 

Considering the request for increase of PCA services is for 24 hours split shift, it is reasonable to conclude there are no informal caregivers who can provide assistance for extended periods of time on a regular basis. As per NYS regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance when needed for daily activities, including ADLs that occur at unscheduled and recurring times throughout the day and night. The time limitations of a live-in aide do not appear compatible with the care needs of the patient; and so continuous personal care services (split shift) are indicated.

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 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 per week is overturned. Medical Necessity is substantiated.