Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Demetria

Treatment personal care assistant (PCA) services of 7 days times 24 hours split shift as not medically necessary

The insurer denied coverage for personal care assistant (PCA) services of 7 days times 24 hours split shift as not medically necessary

The denial is overturned

This patient has extensive medical history of anxiety, cancer, coronary heart disease, depression, dementia, hypertension, gastroesophageal reflux disease without esophagitis, poly-osteoarthritis, hearing loss, abdominal pain, abnormality of gait and mobility, lower back pain, glaucoma and hearing loss associated with functional impairment and needs assistance for all daily activities. The Uniform Assessment System (UAS) indicates patient has one informal caregiver who provides some assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), but the patient primarily relies on personal care services. 

The patient is totally dependent for meal preparation and housework; she needs maximal assistance for shopping, transportation, stairs and extensive assistance for medications, finances and phone use. The patient needs extensive assistance for all ADLs, except eating (supervision) and bed mobility (independent setup help).  The patient needs a caregiver through the day and night to assist with her daily care needs. During the day she needs assistance with all housekeeping related tasks. The patient needs assistance with all routine ADLs i.e., bathing, dressing, personal hygiene; and she needs assistance with all mobility (if she transfer out of bed or uses a wheelchair) and toileting/incontinence care whenever the need occurs.  

MLTC (Managed Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. All the patient's care needs that occur throughout the day and evening/night must be considered in the determination of the patient's personal care service hours. 

Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have a caregiver present during the day and night to provide assistance with all IADLs and ADLs, including ADLs that occur at various unscheduled and recurring times throughout the day and night (including toileting/incontinence care, bed mobility). Without caregiver assistance, the patient is at increased risk for adverse medical events e.g., skin injury (from incontinence and pressure); falls (if she attempts to get out of bed unassisted); nutritional decline, dehydration; poorly controlled pain. 

As per NYS (New York State) regulations for personal care services, 24 hour services can be provided as live-in or continuous (split shift). In order to qualify for 24 hour live-in services, the patient's need for assistance must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep in an 8 hour sleep period per day. If the patient's care needs are too frequent to allow the aide to obtain 5 uninterrupted hours of sleep per day, then continuous services (split shift) are necessary. 

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) does not appear 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, PCA continuous services (split shift) is medically necessary in order to properly and safely meet the patient's care needs throughout the day and night.

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

The insurer's denial of coverage for the requested Personal Care Assistant (PCA) Services of 7 days times 24 hours split shift is overturned. Medical Necessity is substantiated.