Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Diabetes mellitus, Vision loss, Cardiac disease, Depression
Treatment: Personal care aide services at 7 days per week live-in
The insurer denied coverage for personal care aide services at 7 days per week live-in.
The denial is overturned. 

This is a female patient with a history of diabetes mellitus with neuropathy, osteoarthritis, severe vision loss, cardiac disease, and depression. She lives alone and needs assistance with all daily activities. She receives personal care aide (PCA) services, 70 hours per week. Family provides some informal support. Over the past year, the patient has had several hospitalizations associated with functional decline. The family requested increase of PCA services to 7 days per week, live-in. 

Uniform Assessment System (UAS) documentation indicates the patient is totally dependent or needs maximal assistance for all household related tasks and shopping. For activities of daily living (ADLs), the patient no longer walks and relies on others to propel her wheelchair. She is totally dependent for lower body dressing, and needs maximal or extensive assistance for all other ADLs, except eating (limited assistance). Considering the patient's medical history and functional impairment, it is apparent that the patient needs assistance for all daily activities, including ADLs that occur at various times throughout the day and night. Therefore, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day and night to provide assistance for all daily activities. 

The patient needs assistance for daily activities that occur at various scheduled and unscheduled times during the day and night. This includes routine household tasks and other instrumental activities of daily living (IADLs); routine morning and evening ADLs; meals and snacks to ensure adequate and safe food and fluid intake; all toileting and incontinence related tasks; transfers in/out of bed and wheelchair. Without adequate assistance, the patient is at risk for significant adverse events. Frail elderly people are at substantial risk for poor outcomes from acute illness and injury. It is medically necessary to implement a care plan that ensures the patient's basic daily care needs are met to reduce the risk of adverse health events.

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. Considering the family requested PCA services 7 days per week live-in, it is reasonable to conclude that informal caregivers are unable to provide care for extended hours each day on a regular basis. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at various and unscheduled times through the day and night. As per NYS regulations for personal care services, 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, i.e. split shift. The patient will benefit from the additional assistance of live-in services at this time. The maximum amount of PCA services recommended from this review is limited by the amount requested; in this case, live-in services. If re-assessment determines that the patient's care needs are too frequent for a live-in aide, then the plan can be modified.  

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

Based on the above, the medical necessity for the PCA services at 7 days per week live-in is substantiated. The insurer's denial is overturned.