Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, normal pressure hydrocephalus

Treatment: Personal Care Aide (PCA) level 2 services of 24 hour split shift for a total of 168 hours per week.

The insurer denied coverage for PCA level 2 services of 24 hour split shift for a total of 168 hours per week.

The denial is overturned.

The patient is a female with a past medical history of Alzheimer's dementia, normal pressure hydrocephalus, ventricular shunt placement, pulmonary embolism (PE), bronchiectasis, pulmonary disease, breast cancer- status post (s/p) a lumpectomy, urinary incontinence, gait difficulty, and history of falls. Per the New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, her daughter and grandson were present for the assessment. The patient's overall self-sufficiency has deteriorated compared to her status 90 days ago.

The patient was transferred to Upper East Side Rehabilitation and Nursing Center s/p PE and urinary tract infection (UTI), and was later discharged. The patient's grandson has been helping with her care since she returned from the skilled nursing facility. It was noted that the patient lives with non-family roommates in a two bedroom apartment of a private building with elevator access. An increase to personal care aide (PCA) level 2 services of 24 hour split shift for a total of 168 hours per week is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 7/6/16 

(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

On a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.

The recent Uniform Assessment System notes that the patient was instructed in pull-up management and that memory is OK. Medical Doctor (MD) notes, mini-mental-status exams show significant dementia. She can forget to eat and wanders. There are no paid or scheduled informal caregivers. She needs assistance with transfers, ambulation and toileting. These needs plus her forgetfulness make her unreliable as to proper incontinence management. She has deteriorated over the last months and cannot meet her unscheduled needs.  

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

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 24 hour split shift for a total of 168 hours per week is reversed. Medical necessity is substantiated.