Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polyosteoarthritis, hypertension, low back pain
Treatment: Personal care aide (PCA) services live-in, 7 days a week
The insurer denied coverage for PCA services live-in, 7 days a week.
The denial is overturned.

This elderly patient has physical and cognitive impairment associated with various medical conditions and needs assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives alone (her husband died recently). The patient's daughter is identified as the only informal helper. The insurer's final denial letter indicates PCA services had been approved for 2 hours per day, 7 days per week. Daughter's letter reported patient's husband was receiving 24-hour care prior to his death; noted by the daughter as "joint" case for husband and wife; and the patient was receiving care from the 24-hour aide. The daughter reported that when the husband died and his PCA services stopped, the patient no longer had the 24-hour help she relied on for her daily activities, and her functional status declined (daughter reported neurology evaluation was pending). As per insurer's final denial letter, the daughter requested increase of PCA services to live-in, 7 days per week, which was denied; but PCA services were increased to 7 hours per day, 7 days per week. On appeal, denial of live-in services was upheld, but PCA services were increased to 8 hours per day, 7 days per week. 

The most recent Uniform Assessment System (UAS) provided for review was done within recent weeks. Functional status report indicates patient is totally dependent for IADLs, except stairs, transportation (maximal assistance). For ADLs, the patient needs extensive assistance for bathing, personal hygiene, dressing upper/lower body, transfer toilet, toilet use, bed mobility; limited assistance for walking, locomotion, eating.

The physician reported patient has heart failure; stage/class was not noted. UAS does not report symptoms specific to heart failure; but the Service Plan summary noted the patient reported increased fatigue, which is a common symptom of heart failure in older people. The Nurse Practitioner's letter reports lower extremity edema (patient takes diuretic); possibly due to heart failure. Heart failure in older people is associated with functional decline and greater dependence on caregivers for daily activities.

As per New York State (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 in an 8-hour sleep period per day. There are no nighttime activity logs available to help determine the frequency of the patient's nighttime ADL needs. However, the available information supports the patient's need for assistance with daily activities that extend from morning to evening; plus at least some nighttime ADL assistance (e.g., toileting/ incontinence care, bed mobility, out-of-bed mobility).

With live-in services, the patient will benefit from help with ADLs and IADLs during day and evening hours, plus some help at night that is not available to her with current PCA services (8 hours per day). 

Based on the above, the insurer's denial must be overturned. 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) services live-in, 7 days a week is substantiated.