Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal care aide 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 Personal care aide level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week- for a total of 168 hours per week. 

The determination is overturned. 

The patient has a past medical history of hypertension, dementia, hyperlipidemia, osteoarthritis, urinary incontinence, obesity, and major depressive disorder who had been assigned personal care assistant (PCA) services 7.5 hours/day, 6 days/week, to total 45 hours/week based on a telephonic assessment tool assessing the patient at total assistance with task of managing finances while maximum assistance with tasks of meal preparation, ordinary housework, and shopping. The patient was assessed at extensive assistance with tasks of managing medication, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use while limited assistance with task of eating. With the task of phone use the patient was assessed at set up only while independent with task of bed mobility. 

The patient's primary care physician (PCP) provided a letter recommending services from a home health aide at least 60 hours/week to assist her with her activities of daily living as she needed assistance from 8:00 AM to 6:00 PM. The patient underwent a telephonic assessment tool assessing the patient at total assistance with the tasks of ordinary housework and managing finances while maximum assistance with tasks of meal preparation, managing medication, stairs, shopping, transportation, bathing, personal hygiene, dressing upper/lower body, and toilet use. The patient was assessed at extensive assistance with tasks of walking, locomotion, transfer toilet, and bed mobility while limited assistance with task of phone use and eating. This assessment stated the patient had a decline in cognition, had difficulty finding words, reported she did not remember how to make a cup of coffee, and had broken her microwave because she put foil inside of it. This assessment also stated the patient had a decline in activities of daily living (ADL) performance as well as overall self-sufficiency due to cognitive decline and increased stiffness secondary to osteoarthritis. In addition, the assessment stated the PCA assisted with significant weightbearing assistance in the cleaning of patient, changing incontinent supplies, and adjusting members clothes after toileting. The patient had a fall. 
The patient saw her PCP with a note stating the patient had been steadily declining and needed more assistance, had a decline in her activities of daily living, had fallen around 7:30 PM when she was alone and pressed her life alert button and then told them that she was okay, the family had installed cameras in the patient's home, and the patient had no significant injury. 

The insurer sent an initial adverse determination denial notice partially denying the request to increase PCA services and approving PCA services 24 hours/day, live-in, 7 days/week. 

The insurer sent a final adverse determination denial notice denying the request to increase PCA services to 24 hours/day, split shift, 7 days/week stating it was not medically necessary and the patient did not meet criteria. The denial noted that the patient reported an inability to accommodate a live-in aide. In addition, the denial stated that based on assessment and documentation presented there was insufficient evidence that all arrangements for meeting living services had been explored including, but not limited to sleeping accommodations for the PCA. 

Daytime and overnight logs were documented and noted that the patient needed assistance with walking, locomotion, transfer toilet, toilet use, and bed mobility at least every 2 to 2-1/2 hours. 

The patient's daughter provided a letter stating the patient's condition was deteriorating and she was not able to perform tasks independently. The daughter noted that she had installed cameras to monitor her mother. In addition, the daughter noted she could not provide care to the patient due to her own health conditions. Lastly, the daughter's letter stated there was no accommodation for a live-in aide. 

The patient's PCP provided a letter stating the patient had a rapid decline in her functional abilities and is unable to cook, feed, cleaning, laundry, bathe, toilet, or shop as her health conditions had significantly deteriorated and she could not care for herself independently any longer as she once did. The letter stated "I highly urged the insurance company to allot 24-hour care split shift due to the medical necessity of our patient". The patient's healthcare advocate requested an external appeal of the denial decision by insurer. The denial stated there were no accommodations for the live-in aide as required by New York Codes, Rules, Regulations (NYCRR) 505.14 and the agency would not send a live-in aide because there were no accommodations for the aide.
At issue is the medical necessity of personal care aide level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week- for a total of 168 hours per week. 

The services are medically necessary. 

There is documentation of the patient's decline in physical and mental functioning. The patient's medical provider has recommended an increase in PCA services as medically necessary. The insurer approved PCA services live-in services but the patient lives in a one bedroom apartment without accommodations for the aide and overnight logs have shown that the patient has assistance needs with ADLs at least every 2 to 2-1/2 hours. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 x 12 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.