Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, coronary artery disease, chronic renal insufficiency, hypertension, chronic anemia. 

Treatment: Increase in personal care aide (PCA) to 24 hours per day (Split-Shift). 

The insurer denied coverage for increase in personal care aide (PCA) to 24 hours per day (Split-Shift). 

The denial is overturned. 

This male patient has extensive medical history associated with severe functional impairment and is dependent on caregivers for all daily activities. He lives alone and receives some informal assistance from family, but he primarily depends on personal care aide (PCA) services. 

The most recent Uniform Assessment System (UAS) provided for review. The functional status report indicated patient is totally dependent for all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient no longer walks. He is transferred in and out of bed by Hoyer lift and his out-of-bed mobility is in a wheelchair, propelled by others. Most of the time the patient is in bed (as reported by patient's sister). 

The patient is totally dependent for all IADLs, with cognitive impairment as a significant cause, in addition to his physical limitations. Regarding ADLs, in later stages of dementia the affected person may not remember, recognize, or know what to do for basic ADLs. Based on description of the severity of patient's cognitive impairment, it appears the high level of assistance needed for ADLs is probably due to combined effects of physical and cognitive decline. 

The patient is totally dependent for bed mobility, and when he is in pain, movement is even more difficult.  Repositioning may help relieve pain in his spine and/or joints caused by uncomfortable position in bed. The patient is unable to self-medicate due to cognitive and physical impairment. Having a caregiver present to assist with repositioning and/or to assist with providing pain medication is an important aspect of pain management for this patient. Pain relief may also help decrease some of the patient's agitation at night and may help him sleep. 

The aide is responsible for all household tasks; meal preparation; shopping; assistance with all routine ADLs (eating; morning and evening ADLs); plus, toileting/incontinence care day and night (reported in the UAS as every 2-3 hours); repositioning every 2-3 hours for pressure relief, and as needed for pain relief. It does not appear that the patient's daily care needs are compatible with the schedule of a live-in aide, which includes 5 uninterrupted hours of sleep per day on a regular basis. 

The UAS indicates there are two informal caregivers (son and sister, neither live with patient). Considering the request for increase of personal care services is for 24 hours split shift, it is reasonable to conclude that there are no informal caregivers who can provide ADL assistance to the patient for extended periods of time of the day or night on a regular basis. As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance when needed for daily activities, including ADLs that occur at various unscheduled and recurring times throughout the day and night. Live-in services do not appear to meet the care needs of the patient; and so continuous personal care services (split shift) are indicated. 

Recommendation is given to approve Home Care/Personal Care home health care (HHC) Personal Care Aide 24 hours per day (split shift). 

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 an increase in personal care aide (PCA) services to 24 hours per day (Split-Shift) is overturned. Medical Necessity is substantiated.