Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, limited cognitive abilities
Treatment: Personal Care Aide (PCA) Level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week for a total of 168 hours/week (split-shift)
The insurer denied PCA level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week for a total of 168 hours/week (split-shift).
The determination is overturned.

This is a female patient with a history of dementia, hypertension, atrial fibrillation, depression, psoriasis, right knee osteoarthritis, history of falls, and urinary and bowel incontinence. She lives with her husband in a private residence. The patient was previously approved for Personal Care Aide (PCA) services for 36 hours/week. The patient and her care team requested PCA services 7 days/week, 24 hours/day (split shift) for a total of 168 hours/week. This request was partially denied by the Plan, which approved PCA services for 42 hours/week. 

An in-person Uniform Assessment System (UAS) was completed. The assessor documented that the patient's activities of daily living (ADLs) status had declined and her overall self-sufficiency had deteriorated in the previous 90 days.

The patient's orthopedist states that she has severe degenerative osteoarthritis of her right knee and requires 24/7 care for personal hygiene, meals, and mobilization. The patient's primary care physician states that she requires 24/7 care for assistance with personal hygiene, eating, toileting, and mobility. 

The patient's advocate states that the patient's spouse is incapacitated due to his own medical issues and is not able to provide informal support. Her advocate notes that the patient's family provided a letter stating that the patient is required to drink a lot of fluids due to a history of urinary tract infections (UTIs) and therefore frequently uses the toilet during the day and night. At issue is the medical necessity of PCA level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week for a total of 168 hours/week (split-shift).

Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA level 2: 12 hours/day, 7 days/week; 12 hours/day, 7 days/week for a total of 168 hours/week (split-shift) is medically necessary.

The patient lives with her husband and therefore has informal support. However, per New York Codes, Rules, and Regulations (NYCRR) 505.14, the plan cannot assume that the informal support person can provide all needed care outside of the approved PCA hours as informal supports must be voluntary. 

Per NY Codes, Rules, and Regulations section 505.14, a 24-hour live-in PCA must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. An aide to this patient would be unable to receive five hours of uninterrupted sleep. The overnight care logs provided by the patient's aide show that the patient requires assistance with toileting every 2-3 hours overnight. The patient cannot restrict fluid intake in the evening to decrease urinary frequency due to her history of recurrent UTIs; guidelines from UpToDate recommend that women with recurrent cystitis should increase their fluid intake to reduce the risk of recurrence. Therefore, split-shift care is required to meet the patient's frequent care needs.