Appeal type: Medical necessity
Decision: Overturned

Diagnosis: coronary artery disease (CAD), hypertension (HTN), hypothyroidism, hyperlipidemia, gastroesophageal reflux disease (GERD)

Treatment: Personal care aide PCA services of 7 days per week, two 12 hour shifts per day (split shift or 168 hours per week).

The insurer denied coverage for PCA services of 7 days per week, two 12 hour shifts per day (split shift or 168 hours per week).

The denial is overturned.

This female has several medical conditions contributing to functional impairment. The patient is dependent on caregivers for all daily activities. The patient has two sons who provide informal assistance. At the time of the New York State Department of Health's Uniform Assessment System (UAS-NY), the patient was living with one of her sons, but it was reported that he was going to move out soon and the patient would be living alone (it is not known if this has already occurred). The patient has been receiving personal care aide (PCA) services 84 hours per week, 12 hours per day. As a result of a fall, the patient fractured her pelvis. According to her son, the patient's cognition declined following the pelvic fracture. Her physical function also declined. A request was made to increase PCA services to two 12 hour shifts per day (split shift), which was denied; but the insurer approved live-in services. As per the insurer's final denial letter, the son declined live-in services. The patient is still receiving PCA services 84 hours per week. An external appeal was requested for PCA services two 12 hour shifts per day. 

The patient has dementia (vascular type as noted in the UAS) which is probably a substantial cause of her functional impairment. Based on the UAS (with history from the son), it appears the patient has advanced dementia. As per UAS, the patient's decision-making ability for daily activities is severely impaired. She has extensive memory loss. Her communication skills are also substantially limited, and according to the son, her responses do not make sense. She is unable to verbalize her needs; unable to recognize family members. During the telephonic UAS, patient did not respond to questions from the nurse. 

The patient no longer uses a toilet or commode. She is completely incontinent and totally dependent on caregivers for incontinence care. She is also taking a diuretic which can increase urinary frequency. Incontinence occurs at various unplanned times of the day and night; and so a caregiver needs to be available throughout the day and night. Diapers are not the full solution. Even with diapers that have higher absorption, it is unrealistic to expect the patient to remain clean and dry for up to 12 hours per day (when PCA is not present, and no informal caregiver available). Remaining in wet soiled diapers for extended periods of time is inconsistent with medical and nursing standards of care for incontinence and skin care; and can result in incontinence associated skin damage (e.g., dermatitis, fungal infection). Soiled diapers are also a source of discomfort for the patient. The UAS indicates the patient has persistent redness on her buttocks which may be a consequence of incontinence.

The patient has two sons who have been providing informal care; but it was noted in the UAS that both are unable to continue to provide care. There are no other informal caregivers identified in the available records. Considering the request for increase of PCA services is for 24 hours split shift, it is reasonable to conclude that the sons (or other informal caregivers) are not able to provide activities of daily living (ADL) assistance to the patient for extended periods of time of the day or night. As per NYS (new York state) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance when needed for daily activities, including ADLs that occur at various unscheduled and recurring times throughout the day and night.

Personal Care Aide (PCA) services of 7 days a week, two 12 hour shifts per day (split shift or 168 hours per week) are medically necessary. The health plan did not act reasonably with sound medical judgement, and in the best interest of this patient.  

The carrier's denial of coverage for the requested Personal Care Aide (PCA) services of 7 days a week, two 12 hour shifts per day (split shift or 168 hours per week) is overturned.  The medical necessity is substantiated.