Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease (PD)

Treatment:  Personal care aide (PCA) live-in per diem services of 24 hours per day, 7 days per week

The insurer denied coverage for for personal care aide (PCA) live-in per diem services of 24 hours per day, 7 days per week

The denial is overturned.

This elderly male has substantial functional impairment associated with several chronic medical conditions. He depends on caregivers for assistance with all daily activities. He lives alone and receives some informal care from family, but he depends on personal care services for most of his activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient receives personal care aide (PCA) services 10 hours per day, 7 days per week (70 hours per week total). 

The most recent New York State Department of Health's Uniform Assessment System (UAS-NY)  provided for review was done (telephonic). The UAS (Uniform Assessment System) functional status report indicates that the patient needs maximal assistance or total dependence for most IADLs; except finances, (extensive assistance) and phone use (limited assistance). For ADLs, the patient is totally dependent for locomotion (mobility is mostly with wheelchair with caregiver assistance); for other ADLs: maximal assistance is needed for bathing, lower body dressing, walking, toilet transfer, toilet use, eating; extensive assistance for personal hygiene, upper body dressing, bed mobility. 

Functional decline in older people is usually the result of cumulative and interactive effects of multiple medical conditions resulting in physical and/or cognitive impairment. Other factors include economic and social circumstances, (e.g., caregiver support). The patient has several medical conditions that contribute to his impaired ability to perform daily activities. 

The patient has Parkinson's disease (PD) which is a progressive neurodegenerative disorder that affects various types of function. Motor symptoms include tremor, bradykinesia, rigidity, postural instability, slow unsteady gait; all of which can adversely affect ability to perform daily activities.  Non-motor symptoms include autonomic dysfunction (e.g., blood pressure changes including orthostatic hypotension, bowel and bladder dysfunction); cognitive impairment (memory impairment, dementia); mood disorders (anxiety, depression). Other symptoms associated with PD include dizziness, fatigue, pain, sleep disturbances. Falls (often recurrent) occur with PD due to the combined effects of motor and non-motor symptoms.

The need to use the toilet and episodes of incontinence occur at various unplanned times of the day and night. The patient currently has PCA services 10 hours per day. It is apparent that the patient needs to use the toilet or has episodes of incontinence during the other 14 hours of the day. There are some incontinence products with higher absorption capacity; but it is unrealistic to expect the patient will consistently stay clean and dry during non-PCA hours when he has no assistance. The patient is unable to provide self-care for incontinence, so he remains in a wet soiled diaper for extended period of time. This can cause patient discomfort; increases risk for incontinence associated skin damage (e.g., fungal infection, dermatitis), and increases risk of pressure ulcers. 

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 ADLs and IADLs, and with ADLs that occur at various unscheduled and recurring times throughout the day and night (including toileting, incontinence care, transfers, walking, wheelchair mobility, bed mobility). Without a caregiver to provide assistance, the patient is at increased risk for adverse medical and safety events including falls/injury; incontinence associated skin damage; pressure ulcers.  

As per the UAS, the patient has family members who are identified as informal caregivers, but it appears the time they can provide is limited. Considering the request for increase of PCA services is for 24 hour live-in, it is reasonable to conclude that there are no informal caregivers who can provide care for extended periods of time during the day or night.  Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance for daily activities, including ADLs that occur at unscheduled and recurring times throughout the day and night.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Live-In Per Diem Services of 24 hours per day, 7 days per week is reversed. Medical necessity is substantiated.