Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease; osteoarthritis,
 
Treatment: Personal care aide services 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 personal care aide services 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 reversed. 

This patient is a female who has Alzheimer's disease hypertension, hyperlipidemia, urinary incontinence, depression, osteoarthritis, constipation, and tinea pedis. The patient has severe functional impairment. She lives alone and is currently approved for personal care aide (PCA) services 9 hours per day, 7 days per week. Family provides some help (administer medications; other tasks not identified). A relative requested increase of PCA hours to 12 hours x 2, split shift (24 hours per day), 7 days per week. The insurer denied request. The patient is dependent on caregivers for all IADLs (total dependence or maximal assistance). She needs maximal (weight-bearing) assistance for all ADLs, except eating (total dependence; as per son, patient will skip meals if not fed by a caregiver). Based on the patient's medical history, it appears several medical conditions contribute to the patient's functional decline. 
Another concern is the patient's bed mobility, which requires maximal assistance. Considering the patient is dependent on caregiver help for all ADLs, it is reasonable to conclude that the aide prepares the patient for bed and helps her into bed before the aide leaves each day. Even if the family helps in the evening, there is no documentation indicating an informal caregiver is with the patient during the night. Therefore, the patient is unable to reposition herself during the night. The patient may need repositioning due to pain and discomfort. Inadequate turning and repositioning for extended hours during the night increases the risk for pressure ulcers; with additional risk if the patient is lying is wet, soiled diapers/pads. For a patient with limited bed mobility and incontinence, pressure ulcer prevention is a priority.

The patient is not able to transfer or walk without substantial assistance. However, the patient has impaired judgment and poor safety awareness. Even though she cannot safely get out of bed alone, she may attempt to get out of bed, not considering the risk of falling. If a caregiver is present, the patient can either be assisted back into bed, or assisted out of bed. The patient has h/o falls, and has multiple risk factors for falls including: arthritis, chronic pain, unsteady gait, dizziness, incontinence, cognitive impairment, advanced age, previous falls, medications associated with increased risk of falls (e.g. antidepressant, antihypertensive drugs). Falls in the elderly can result in serious injuries (e.g. fractures, head trauma), associated with increased morbidity and increased risk of death

Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services. Considering the son is requesting 24 hour PCA services as 12 hours x 2 split shift, it is reasonable to conclude that there are no informal caregivers who can provide consistent and adequate hours of assistance to the patient to meet all of her care needs when the PCA is not present.

Personal Care Aide 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 medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the increase to personal care aide services 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 substantiated. The insurer's denial is reversed.