Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Parkinson's disease, Osteoarthritis
Treatment: Personal Care Aide services 7 days per week 24 hours, 2/12 hours split shift (168 hours per week)
The insurer denied coverage for Personal Care Aide services 7 days per week 24 hours, 2/12 hours split shift (168 hours per week).
The denial is overturned. 

This is a male patient who has an extensive medical history and substantial functional impairment. His medical history includes advanced Parkinson's disease, Lewy body dementia, aphasia, polyneuropathy, chronic headaches, vertigo, neck pain, insomnia, depression, hypertension, benign prostatic hyperplasia, anemia, coronary artery disease, diabetes mellitus, glaucoma with right eye blindness, and osteoarthritis. He lives at home with his wife, who is the only identified informal caregiver. He receives personal care aide (PCA) services 77 hours per week. The patient (via designee) requested increase of PCA services to 24 hours, 2-12 hours split shift which was denied. 

The Uniform Assessment System (UAS) functional status report indicates that the patient is totally dependent for household tasks and shopping; other instrumental activities of daily living (IADLs) need maximal or extensive assistance. The patient's activities of daily living (ADLs) need maximal or extensive assistance, except eating (limited assistance) and bed mobility (supervision). The patient's cognitive status indicates significant areas of impairment. The diagnosis list indicates dementia. Patient has Parkinson's disease; and so dementia may be at least partly associated with Parkinson's disease. Decision making for daily life is noted as minimally impaired; short term, procedural and situational memory is impaired; he has periods of confusion; unable to verbalize emergency plan, confuses day and night; has delusions. The patient has significant physical impairment, but it is likely the patient's cognitive deficits also contribute to his overall functional impairment.

Considering the information provided for review, including the patient's medical history and functional limitations, it is medically necessary and in the patient's best interest to have a caregiver present and available to provide care throughout the day and night in order to prevent adverse health and safety events. The patient currently receives PCA services 11 hours per day, 7 days per week. However, the patient needs assistance with ADLs that cannot be scheduled, and occur at various times of the day and night. The patient's wife is unable to continue providing informal care. There are no other informal caregivers identified in the records provided for review. 

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. Without informal caregivers who can provide care when needed on a consistent basis, then personal care services are indicated to provide assistance with daily activities, including ADLs that occur throughout the day and night. The request for increase of PCA hours is for 24 hours split shift. Considering the patient's limited sleep at night, his frequent need to use the toilet, frequent urinary incontinence, history of pressure ulcers, his fall risk and history of falls, the patient requires assistance with transfers, walking, toileting, incontinence care, assistance/supervision with bed mobility at a frequency that does not appear compatible with the 5 hour sleep requirement for a live-in aide (as per NYS regulations for live-in aide services). Therefore, PCA 24 hours continuous services, split shift, are medically necessary to meet the patient's care needs. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for Personal Care Aide services 7 days per week 24 hours, 2/12 hours split shift (168 hours per week) is substantiated. The insurer's denial is overturned.