Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Age related cognitive decline, ischemic heart disease, heart failure, atrial fibrillation

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day-7 day(s) per week; 12 hours per day-7 day(s) (split shift)-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) (split shift)-A total of 168 hours per week. The denial is reversed.

This patient is a female with an extensive medical history and severe functional impairment. She was living at home with assistance from personal care aide (PCA) 12 hours per day. The patient's relative is the only identified informal caregiver. Request was made to increase PCA services to 24 hours split shift (two 12 hour shifts), which was denied by insurer. An external appeal was requested by the patient advocate. The patient has complex medical history including extensive cardiac disease (ischemic heart disease, heart failure, atrial fibrillation), diabetes mellitus (DM) type 2 with neuropathy, osteoarthritis, urinary incontinence. The diagnosis list includes age related cognitive decline; the description of patient's mental status in the UAS suggests substantial cognitive impairment. 

The patient's functional status as described in the UAS indicates the patient needs either maximal assistance or total dependence for all IADLs and ADLs. The patient is totally dependent on caregivers for all household related tasks. She is non-ambulatory. She needs maximal assistance for all self-care activities. She is incontinent and needs assistance for all toileting related tasks including incontinence care. In the insurer's final denial letter, there was no explanation as to how the patient could manage any self-help activity for 12 hours each night. The patient cannot transfer out of bed, walk to the bathroom, transfer to a commode, provide self-care with toileting/incontinence care, reposition herself in bed (for pressure and pain relief), self-administer medication (e.g. for pain) without maximal (weight-bearing) assistance. This level of dependence on caregiver assistance is documented in the UAS which was noted in the insurer's final denial letter as the primary source of information for the determination to deny 12 hours x 2, split shift PCA services for the patient. Other sources of information reviewed by the insurer (physician letters, advocate's letter, night shift logs, medical records) all supported the need for 24 hour PCA services.

Based on the information in the UAS, supported by the physicians' letters, medical records, and the night time activity logs, it is medically necessary for the patient to have assistance with ADLs throughout the day and night; including toileting/incontinence care and turning and repositioning through the day and night for proper skin care and pain management. The night time activity logs indicate the patient frequently needs assistance provided by a caregiver.  It does not appear that a live-in aide could expect to have 5 uninterrupted hours of sleep per night (as required in NYS regulations for live-in aides); therefore, split shift PCA services are necessary. 

Based on the above, the medical necessity for Personal Care Aide (PCA) Level 2: 12 hours per day-7 day(s) per week; 12 hours per day-7 day(s) (split shift)-A total of 168 hours per week is substantiated.  The insurer's denial is reversed.