Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease (ESRD). 
Treatment: Personal Care Aide (PCA) Services, Level II, 7 days per week, 24 hours a day, live-in. 

The insurer denied coverage for PCA Services, Level II, 7 days per week, 24 hours a day, live-in.  The denial is overturned. 

This is a female patient with an extensive medical history and functional impairment who needs assistance with all daily activities. As per the Uniform Assessment System (UAS) report, she has 4 daughters; 2 serve as Consumer Directed Personal Assistance Program (CDPAP) aides. The patient is approved for personal care aide (PCA) services 70 hours per week. The request was made to increase PCA services to 24 hours live-in.

UAS documentation was provided for review. The patient needs maximal assistance or total dependence for all instrumental activities of daily living (IADLs), except managing finances and medications, and phone use (limited assistance).  The patient needs extensive assistance with all activities of daily living (ADLs), except personal hygiene, bed mobility (limited assistance) and eating (independent setup help). The patient has several medical conditions that most likely contribute to her decreased ability to perform daily activities. She has end stage renal disease (ESRD) and she is on hemodialysis 3 times per week. Her cognitive status appears mildly impaired (memory loss, some difficulty with decisions). At this time, it is medically necessary and in the patient's best interest to increase PCA services to include evening/nighttime assistance; specifically to address her toileting/incontinence care needs; and facilitate healing of skin injuries that exist and prevent occurrence of new skin problems (related to incontinence and/or pressure). 

As per New York State (NYS) regulations for personal care services, 24-hour care can be provided as live-in services or continuous care (split shift).  In order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8-hour sleep period each day. If the patient's care needs are of such high frequency that the aide cannot have this amount of sleep on a regular basis, then continuous services are indicated. As per NYS regulations for personal care services, assistance from informal caregivers is voluntary. It cannot be assumed or expected that the patient's daughters can provide additional care at night as informal helpers. Considering the request for increase of personal care services is for 24 hours live-in, it is reasonable to conclude that informal caregivers are not able to provide the extended hours of care needed during evening and night hours on a long term basis. 

The frequency of assistance needed at night is not noted in the available records, except for the physician's recommendation for repositioning every 2 hours. However, considering the decline in the patient's condition (decreased mobility and occurrence of pressure ulcers) it is medically necessary to increase the patient's personal care assistance to include the evening and night. 

The maximum amount of services that can be approved from this review is limited by the amount of services requested, as per the insurer's final adverse determination notice; in this case, PCA services 24 hours per day live-in. Continuous (split shift) services exceed the service time (hours per day) of a live-in aide; and so cannot be approved from this review.  It would not be in the patient's best interest to deny evening and night services at this time. Live-in services would provide necessary additional hours of care that are currently unavailable. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for PCA Services, Level II, 7 days per week, 24 hours a day, live-in is overturned. The medical necessity is substantiated.