Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, hypertension, and a stroke

Treatment consumer and self-directed personal assistance services of 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The insurer denied coverage for consumer and self-directed personal assistance services of 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The denial is overturned

This female has severe functional impairment and requires substantial assistance for all daily activities. The patient lives alone. Her daughter is the only informal caregiver identified in the New York State Department of Health's Uniform Assessment System (UAS-NY). The patient receives Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week. The daughter is the CDPAS aide and provides care during the day. It is reported in the Uniform Assessment System (UAS) that the daughter hires an aide for the night hours; but she cannot afford to continue private hire care for her mother. Request was made for increase of CDPAS to 24 hours split shift, which was denied. An external appeal was requested. 

People with advanced dementia are often unable to report pain with usual verbal communication and may express pain through changes in behavior (e.g., agitation; restlessness or decreased activity; sleep disturbance; decreased appetite). It is unclear to what extent pain may be a factor in the patient's difficulty with daily tasks. Avoidance of movement that aggravates pain may contribute to low level of function for various daily activities. The daughter reported that the patient often does not participate in activities of daily living (ADLs). If the patient is experiencing joint pain of upper and/or lower extremities, this may be limiting her ability to perform ADLs.

There are significant adverse consequences and risks associated with the patient's functional impairment.

Regarding toileting, the patient is totally incontinent of bladder and bowel (noted in UAS as no control). She is dependent on caregivers for all aspects of toileting/incontinence care. The patient is usually in bed or wheelchair. It is not clear whether caregivers still transfer the patient to the commode. Based on description of the patient's cognitive status and impaired communication, it appears unlikely that the patient consistently informs the caregiver when she needs to use the toilet or when she has an episode of incontinence; and so the caregiver needs to check the patient for incontinence on a regular basis. 

Based on information provided for review, the patient's need for ADL care that occurs at unscheduled and recurring times throughout the day and night (incontinence care, repositioning) is not compatible with the hours of service provided by a live-in aide (i.e., aide is unavailable to provide care during 5 uninterrupted hours of sleep each day). Therefore, CDPAS continuous services (split shift) is medically necessary in order to properly and safely meet the patient's care needs throughout the day and night.

It is not clear whether the aide for the other 12 hours of the day will be providing services as CDPAS or if the family chooses to have standard PCA (personal care aide) services. This approval for 24 hours continuous services, split shift applies to personal care services provided through CDPAS, or standard PCA services, or a combination of both.

Consumer Directed Personal Assistance Services 24 hours per day, 7 days per week (split shift), total of 168 hours per week is medically necessary. The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient. 

The insurer's denial of coverage for the requested Consumer and Self-Directed Personal Assistance Services of 24 hours per day, 7 days per week (split shift) for a total of 168 hours per week is overturned. Medical necessity is substantiated.