Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular dementia, Cardiovascular and Cerebrovascular disease, and Chronic pain.
Treatment: Personal Care Aide (PCA) services of 7 days a week, 24 hours a day (live-in).

The insurer denied coverage for PCA services of 7 days a week, 24 hours a day (live-in).  The denial is overturned. 

This is a female patient who lives alone and needs assistance for most daily activities due to functional impairment from multiple medical conditions. She receives some help from family (details not provided). She has been approved for Personal Care Aide (PCA) services 12 hours per day, 7 days per week. The patient (via designee) requested increase of PCA services to 24 hours live-in services.  

Uniform Assessment System (UAS) documentation was provided for review. The patient is totally dependent for housekeeping tasks. She needs maximal assistance for meal preparation, shopping and managing finances; all other instrumental activities of daily living (IADLs) need extensive assistance. For activities of daily living (ADLs), the patient needs extensive assistance with bathing and dressing; limited assistance for all other ADLs, except bed mobility and eating (independent setup help). The patient has a diagnosis of vascular dementia; significant cardiovascular and cerebrovascular disease; and chronic pain. Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have a caregiver present through the day and night to provide assistance with all routine daily activities, and with ADLs that occur at various and unplanned times throughout the day and night (including toileting, incontinence care, walking, transfers). Without a caregiver to provide assistance, the patient is at high risk for falls/injuries during mobility around her home; and at risk for skin damage due to inadequate incontinence care. 

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance for all necessary daily activities, including ADLs that occur at various and unscheduled times throughout the day and night.

The request for increase of PCA services was for 24 hours live-in services. As per NYS regulations for 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 ADL needs are too frequent to allow the aide to obtain 5 uninterrupted hours of sleep per day, then continuous services (split shift) are necessary. The information provided for review does not indicate frequency of the patient's nighttime care needs. However, the available records support the need for caregiver assistance with toileting, incontinence care, transfer and walking during day, evening and nighttime hours. It is medically necessary and in the patient's best interest for her to have assistance with ADLs during evening and night hours. She will benefit from improved safety with ADLs, and proper delivery of care for toileting and incontinence.

The maximum amount of services that can be approved from this review is limited by the amount of services requested as described in the insurer's final adverse determination notice; in this case 24 hours live-in services. With a live-in aide, the patient will have ADL assistance during the day, evening and night, which she is not receiving with the current services (12 hours per day). 

The health plan did not act reasonably with sound medical judgement, and in the best interest of this patient.  

The carrier's denial of coverage for PCA services of 7 days a week, 24 hours a day (live-in) is overturned. The medical necessity is substantiated.