Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional decline
Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week.
The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week.
The denial is reversed.

This elderly patient has an extensive medical history associated with substantial functional impairment. The patient needs assistance with all daily activities. She lives alone and relies primarily on personal care aide (PCA) services. She had been receiving PCA services 63 hours per week. The patient's son (patient designee) requested an increase of services to 24 hours per day, two 12 hours shifts (split shift), 7 days per week, which was denied; but the plan approved PCA 24 hours per day live-in services, 7 days per week. 

The most recent Uniform Assessment for New York (UAS-NY) was provided for review. Functional status report indicates patient is totally dependent for all instrumental activities of daily living (IADLs) except managing medications and transportation (maximal assistance). Patient needs maximal assistance for all activities of daily living (ADLs), except dressing lower body, toilet use (total dependence). The prior UAS reported patient needed maximal assistance for all ADLs. 

Functional decline in the elderly is usually the result of cumulative and interactive effects of the person's medical conditions. Other factors include social and economic circumstances (e.g., caregiver support). Accelerated periods of functional decline can occur in response to new/acute medical events. As people age, functional reserve decreases; and so, when a new medical problem occurs and results in further functional decline, it may be more difficult to return to the prior level of function. Rehabilitation can help, but there may be limits to improvement due to underlying medical conditions. For example, with cardiac disease, decreased endurance and limited activity tolerance may limit participation with rehab. With dementia, the person may not remember skills learned in rehab. If a caregiver is not present at home to give cues/reminders with ADLs/IADLs, improvement may diminish after rehab ends. 

In addition to multiple chronic medical conditions, the records indicate the patient was hospitalized twice in the months prior to the appeal, once for pneumonia and once for cerebellar stroke. Comparison of the most recent UAS and the earlier UAS indicate signs of physical and cognitive decline. It was noted in the Clinical Review Checklist that the patient was receiving physical therapy at home following the stroke, but no rehabilitation records were provided for review. The physician's letter indicated patient's physical and mental condition worsened since the stroke and she is dependent on caregivers for her personal care needs. Even if there was some improvement from physical therapy, the physician's letter indicates the patient still has significant functional impairment and depends on caregivers for assistance with daily activities.

The physician's letter and the most recent UAS indicate patient has dementia. The most recent UAS describes the patient's decision making for daily tasks as moderately impaired - decisions consistently poor or unsafe; cues/supervision necessary at all times (earlier UAS reported decision making as minimally impaired). As of the most recent UAS, the patient was oriented x 1; she had short term, procedural and situational memory problem (earlier UAS reported patient was oriented x 2-3 with short term memory problem; son reported patient is very forgetful). The most recent UAS reported patient is easily distracted; she has difficulty remembering son's name; needs re-direction with all tasks. There were no specific behavioral problems identified, but the son reported patient becomes more disoriented at night. The patient's communication ability was reported in the most recent UAS as limited to making concrete requests; episodes of disorganized speech; patient responds only to simple, direct communication (this is a decline in communication compared to the earlier UAS). It appears the patient had signs of cognitive impairment at the time of the earlier UAS, with further cognitive decline noted by the most recent UAS.  

Based on information in the available records, the patient's activities of daily living (ADL) and instrumental (I)ADL care needs include: all housekeeping tasks; meal preparation/service; assist with eating; assist with medications; routine morning and evening ADLs; unscheduled and/or recurring ADLs during the day and night (i.e., toileting, incontinence care; out-of-bed mobility, repositioning). With consideration of the patient's medical history, her physical and cognitive status, and the time commitment needed from the aide to effectively perform all routine and unscheduled tasks during the day and night, there does not appear to be a consistent predictable 5-hour time period each day when a live-in aide can sleep. With 24-hour split shift services in place, a detailed account of the patient's care needs during the day and night can be obtained from the aides. This information can help with re-assessment to determine frequency of care, and whether the plan needs modification. At this time, based on the information provided for review, the patient's daily care needs can be best served with 24-hour continuous (split shift) services.
 
Based on the above, the insurer's denial must be reversed. 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 assistance (PCA) services level 2: 12 hours per day - 7 days per week; 12 hours per day 7 days per week - split shift - for a total of 168 hours per week services is substantiated.