Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident (CVA), bed confinement, pressure ulcer of the heel, and hemiparesis.

Treatment: personal care aide (PCA) level 2: 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week

The insurer denied coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week 

The insurer's denial was overturned

According to the documentation submitted, this is an adult with a history of hypothyroidism, benign prostatic hypertrophy (BPH), hypertension, hyperlipidemia, percutaneous endoscopic gastrostomy (PEG) tube placement, diabetes, gastroesophageal reflux disease (GERD), cerebrovascular accident (CVA), bed confinement, pressure ulcer of the heel, and hemiparesis. Per the Uniform Assessment for New York (UAS-NY) the patient lives alone in a three-bedroom home with 13 steps walk up. The patient is nonverbal and incoherent. The patient is disoriented to person, place, and time. The patient requires total dependence with meal preparation, housework, managing finances, managing medications, phone use, stairs, transportation, equipment management, bathing, personal hygiene, dressing, walking, toileting, and bed mobility. The patient is bedbound. 

The increase in assistance hours was needed as the patient was bedbound and needed to be repositioned every 2 hours to prevent bedsores. He was dependent on all activities of daily living such as feeding, bathing, transferring, incontinence care, and medications. He had bladder incontinence and had a catheter. He was incontinent of bowel and needed to be changed frequently. The UAS-NY assessments indicated that the patient was totally dependent in activities of daily living including bathing, personal hygiene, dressing upper and lower body, locomotion, toilet use, bed mobility, and eating. Both assessments indicated that the patient was bedbound and incontinent. The most recent assessment indicated that the patient has severe impaired cognition and was nonverbal. He was unable to bear weight and was dependent on others. It was also noted that the patient had a pressure ulcer to the heel of the foot and back when he was discharged from skilled nursing facility. The patient was totally dependent and could not make use of any equipment without physical assistance from an aide. Per the physician's order, the patient needed to be repositioned every 2 hours. 

Per the cited sources, patients who require uninterrupted care by more than 1 personal care aide for more than 16 hours in a calendar day may be appropriate for 24-hour split shift services when a personal care aide is unable to obtain 5 hours daily of uninterrupted sleep during the 8-hour sleep schedule. In this case, the patient requires both total care at night and during the
day. Given the frequent repositioning needed as well as management of tube feeding and suctioning, a care aide would not be able to obtain uninterrupted 5 hours of sleep in an 8-hour sleep schedule. The use of personal assistance is crucial for patients with disabilities to allow them to remain in the community as opposed to being placed in institutional settings. Given the patient's significant healthcare needs, the requested 12-hour split shift is medically necessary. As such, the personal care aide level 2: 12 hours/day - 7 days/week and 12 hours/day 7 days/week split shift for total of 168 hours/week is medically necessary. 
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week services is substantiated.