Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, generalized pain, diabetes, hypertension, gastro-esophageal reflux disease, spinal stenosis, anxiety, depression, other dementia and pneumonia

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) - a total of 168 hours per week

The insurer is denied coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week

The denial is overturned. 

This female has extensive medical history associated with functional impairment and needs substantial assistance with all instrumental activities of daily living (IADLs) and activities of daily living (ADLS). The patient lives alone and receives personal care aide (PCA) services for help with all daily activities.

The patient is high risk for pressure ulcers due to several factors including incontinence and severely impaired mobility. Dementia and chronic kidney disease (CKD) are also associated with increased risk of pressure ulcers.
 
The Uniform Assessment System (UAS) indicates the patient needs maximal assistance from caregivers for bed mobility; and so it is necessary to have a caregiver present to reposition the patient on a regular basis throughout the day and night (in bed and wheelchair). If the patient has a pressure relief mattress on her bed, this is useful; but repositioning a person who is high risk for pressure ulcers is still necessary in order to fully remove pressure from an area of the body (e.g., sacrum, hips). Standard practice for pressure ulcer prevention generally includes repositioning every two hours, though this can vary with certain circumstances. 

The patient is at high risk for falls.  Risk factors include arthritis, pain lower extremities, impaired balance, dizziness, incontinence, dementia, history of falls, advanced age, use of medications associated with falls (antidepressant). Considering the patient's medical history and functional impairment, it is medically necessary, and in the patient's best interest to have a caregiver present and available to provide assistance for all ADLs and IADLs, including ADLs that occur throughout the day and night. 

The patient's daughter is identified as an informal caregiver, but she reported that she is unable to provide the level of assistance the patient needs due to various circumstances (e.g., fulltime job, husband's health issues). The family has been providing additional assistance with privately hired aide, but this is no longer financially possible. The patient is receiving PCA 24 hours per day live-in services. Considering the family is requesting change to 24 hours per day split shift services, it is reasonable to conclude that there are no informal caregivers who can provide assistance to the patient for 11 hours per day when the live-in aide is not working, including 5 uninterrupted hours per day for sleep. Assistance from informal caregivers is voluntary, as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance with all daily activities when needed. 

The patient has advanced dementia and other chronic medical conditions contributing to her poor functional status. Based on the records provided for review, continuous personal care services (i.e., 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 personal care aide (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week is overturned. Medical necessity is substantiated.