Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive supranuclear palsy, Dementia

Treatment: Personal Care Aide services, 7 days x 24 hours live-in

The insurer denied coverage for Personal Care Aide services, 7 days x 24 hours live-in.

The denial is overturned.

This is a male patient with a medical history of chronic liver disease, bladder cancer, and progressive gait unsteadiness with multiple falls. The patient was diagnosed with a neurodegenerative condition, probable atypical parkinsonian syndrome - progressive supranuclear palsy (PSP). He has dementia secondary to PSP and requires assistance with activities of daily living (ADLs) due to his severe neurological deficits and cognitive decline. The patient has had progressive decline for several years resulting in substantial functional impairment (physical and cognitive decline). He lives alone with personal care aide (PCA) services approved for 54 hours per week. The family considers 24 hour care necessary. A request for 24 hour live-in services was denied by the insurer.

Documentation from the Uniform Assessment System (UAS) functional assessment indicated that the patient needed maximal assistance or was totally dependent for most instrumental activities of daily living (IADLs), except transportation (extensive assistance) and phone use (limited assistance). For ADLs, the patient needed maximal or extensive assistance with bathing, lower body dressing and toilet use and limited assistance with all other ADLs, including walking. The UAS assessment for cognition indicated that the patient has memory problems and some impairment with daily decision making. The patient is disoriented to time and place, his short term memory is significantly impaired; he cannot retain new information, and cannot follow simple instructions.

The patient's functional status is substantially impaired due to physical and cognitive decline, requiring assistance with all daily activities. With consideration of the clinical features and complications associated with PSP, the patient is at high risk for adverse health and safety events. The patient's plan of care should include caregiver assistance with all daily activities to help decrease the occurrence of complications such as falls/injuries, skin damage, aspiration, pneumonia. Providing supportive care is an essential part of managing PSP. Therefore, it is medically necessary for the patient to have caregiver assistance with all daily activities, including ADLs that occur at unpredictable times throughout the day and night (e.g. transfers, walking, toileting, incontinence care).

The family is supportive and involved in the patient's care; but it does not appear that there are informal caregivers who can provide extended hours of care each day. The family has provided privately hired aide services for the hours the PCA is not with the patient. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis for the services needed (including privately financed services), then personal care services are indicated to provide the patient with assistance for daily activities when necessary throughout the day and night. As per NYS regulations for live-in aide services, the patient's need for assistance should be sufficiently infrequent to allow the aide to have 5 uninterrupted hours of sleep in an 8 hour sleep period per day. If the patient requires more frequent assistance, and the sleep requirement is not met, then continuous services are indicated. As per the insurer's final denial letter, the family requested 24 hour live-in services; and so the maximum amount of services that can be approved from this review is for PCA 24 hour live-in. 

PCA services, 7 days x 24 hours live-in is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. The insurer's denial is overturned.