Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia; anxiety and depression; chronic pain including osteoarthritis; diabetes mellitus and polyneuropathy; benign paroxysmal vertigo; weakness and fatigue; and dyspnea with moderate activity. 

Treatment: Personal Care Aide (PCA) Level 2 Services of 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 Services of 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week. 

The denial is overturned. 

This is a female patient who has multiple medical problems and functional decline due to physical and cognitive impairment. The patient needs substantial assistance with most daily activities. She is currently receiving personal care aide (PCA) services 49 hours per week; and some informal care (from sister and nephew). The nephew (as patient designee) requested increase of PCA services to 12 hours x 2 per day, split shift, which was denied by the insurer. 

Uniform Assessment System (UAS) documentation was provided for review. The patient needs a high level of assistance for instrumental activities of daily living (IADLs): total dependence for meal preparation, housekeeping tasks, shopping, finances; maximal assistance for phone use; extensive assistance for medications, stairs, and transportation. The patient needs extensive assistance for all activities of daily living (ADLs) except eating (supervision). Some probable causes of the patient's functional decline include: dementia; anxiety and depression; chronic pain including osteoarthritis; diabetes mellitus and polyneuropathy; benign paroxysmal vertigo; weakness and fatigue; and dyspnea with moderate activity. Considering the patient's medical conditions and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present 24 hours per day to provide assistance for all routine ADLs and IADLs throughout the day; and ADLs that occur at various and unscheduled times throughout the day and night including: transfer, walking, toileting/incontinence care; repositioning in bed. 

The patient's nephew and sister are supportive and have provided informal assistance; but based on the available information it appears neither can provide extended hours of care each day on a consistent and long term basis. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. Considering the family is requesting PCA services 24 hours per day split shift, it is reasonable to conclude there are no informal caregivers who can provide care for extended periods of time each day. Therefore, personal care services are indicated to provide assistance with the patient's ADL and IADL care needs when needed throughout the day and night. 

Considering the amount of care the patient needs for routine IADLs and ADLs, plus ADL assistance needed at various and unscheduled times of the day and night, it appears unlikely that a live-in aide would be able to meet all the patient's care needs and have time for 5 uninterrupted hours of sleep per day on a regular basis. Therefore, at this time, PCA services are indicated for 24 hours continuous care (slit shift). Re-assessment will determine whether this will continue to be the best plan for the patient. 

Personal Care Aide Level 2: 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 judgement in the best interest of the patient. 

The carrier's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week (split shift) for a total of 168 hours per week is overturned. The medical necessity is substantiated.