Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease, impaired hearing, asthma, insomnia, anxiety, depression, arthritis and hypertension
Treatment: Personal Care Aide (PCA): 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift), total of 168 hours per week
The insurer denied coverage for Personal Care Aide (PCA): 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift), total of 168 hours per week.
The denial is overturned.

 
This is an elderly female with chronic medical problems including Alzheimer's Disease, impaired hearing, asthma, insomnia, anxiety, depression, arthritis and hypertension. The patient lives alone and recently lost her informal care give (sister-in-law) for nights due to death.  She needs maximal assistance with weight bearing for walking. She is incontinent of urine at times increasing her risk for falls.  
  
The NYS Comprehensive Assessment form was reviewed. The patient's cognitive skills are described as impaired and she has some memory loss.  She is assessed as requiring extensive assistance for all of her Instrumental Activities of Daily Living (IADL) and ADL (Activities of Daily Living) tasks including meal preparation, ordinary housework and shopping, dressing, bathing and needs extensive assistance for weight bearing. The hours approved assist her with the tasks listed above and for personal hygiene and to prevent increased risk of falls and further skin breakdown.  She requires frequent diaper changes. Her doctors believe, reported in a documented letter, that she is at high risk for falls due to wandering and confusion secondary to Alzheimer's disease.  She is also incontinent of urine at times increasing her risk of falling and sustaining a serious injury.  She has fallen multiple times in the past year and her physicians have noted frequent bruising.  Aides have found the floors wet and soiled with feces when arriving in the am due to overnight events.  The patient has been found on the floor multiple times in this condition.

Personal care assistant (PCA) hours are approved primarily to provide hands-on assistance for completion of IADL/ADL (Instrumental Activities of Daily Living/Activities of Daily Living) tasks when no one else is available to provide assistance. 
 
Based on the enclosed documents reviewed, the patient's health and safety cannot be appropriately provided and maintained with only 84 PCA hours/week. She has the means for emergency assistance but cannot use the emergency devices reliably. She is at high risk for falls and wanders secondary to Alzheimer's disease. Her incontinence and inability to cleanse her feces lead to even higher risk for falls and increased skin breakdown.   
 
The carrier's denial of 168 hours split shift for 24 hours a day for 7 days per week of PCA services is not medically appropriate due to high risk of falls with potential for serious injury, wandering and the need for frequent toileting and diaper changes at night to prevent falls and skin breakdown.  The patient cannot be safely managed at night without this level of care. 

Based on the above, the insurer's denial must be reversed. 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 Personal Care Aide (PCA): 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift), total of 168 hours per week is substantiated.