Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus, hyperlipidemia, unspecified dementia without behavioral disturbance. 
Treatment: Personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The insurer denied coverage for PCA level 2 services of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The denial is overturned. 

This is the case of a female with significant functional impairment associated with various medical conditions who requires substantial assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The New York State Department of Health's Uniform Assessment System (UAS-NY) indicates the patient lives alone in an apartment on the 2nd floor of a private house. The patient receives personal care aide (PCA) services 7 hours per day, 7 days per week. 

The patient is dependent on caregivers for all IADLs, which is mostly due to her physical limitations to perform these tasks (e.g., housework, preparing meals, shopping); but it is likely that cognitive impairment is a factor with tasks such as managing finances and medications, and phone use. It appears the patient's physical impairments are the primary cause of her need for assistance with ADLs; however, memory loss and impaired ability to make safe decisions can contribute to problems with ADL function. 

The UAS indicates the patient needs maximal assistance for all toileting related tasks, i.e., toilet transfer and toilet use (which includes incontinence care); and involves transfer and walking to the toilet (or commode). Based on the advocate's report, it appears the patient is usually in the living room during the day, so she needs to be assisted to other locations in the home for toileting, eating in the kitchen, going to the bedroom in the evening. The daughter reported that her mother needs to go to the toilet 2-3 times. It appears the patient can still recognize the need to use the toilet; and so, if she can safely be assisted with toileting related tasks, this will help decrease frequency of incontinence, which will decrease risk of incontinence associated skin complications (e.g., dermatitis, fungal infection). 

Managed Long-Term Care (MLTC) policy 16.07 states that all plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. The patient's ADL care needs throughout the day must be considered in the determination of the patient's personal care service hours, with consideration of the availability of informal caregiver assistance. 

Based on the information provided for review, the patient's need for assistance with daily activities cannot be adequately met with PCA services 7 hours per day. The patient needs caregiver assistance with all daily activities at various scheduled, unscheduled, and recurring times of the day and night. The daughter (the only identified informal caregiver) can continue to provide care during the 12 hours the patient is in bed at night; but cannot manage the weight-bearing effort needed to safely assist the patient with out-of-bed mobility and toileting related tasks after the PCA leaves until the patient goes to bed for the night. Therefore, personal care services are medically necessary to provide all ADL and IADL care 12 hours per day (7 hours currently authorized plus 5 additional hours). This is consistent with NYS regulations for personal care services and MLTC policy 16.07. Based on the submitted documentation, Personal Care Aide services Level 2: 12 hours per day, 7 days per week; total of 84 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 Services of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical necessity is substantiated.