Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced Lewy body dementia.
Treatment: Personal Care Aide (PCA) services 24 hours per day (split shift).

The insurer denied coverage for PCA services 24 hours per day (split shift). The denial is overturned. 

This is a male patient who has advanced Lewy body dementia. He lives with his son who is identified in the Uniform Assessment System (UAS) report as the primary and only informal caregiver. The patient has several other medical conditions also contributing to his functional impairment and need for assistance with daily activities. The patient receives personal care aide (PCA) 24 hours per day live-in services. The patient's son is requesting PCA services 24 hours per day split shift. 

The functional status report from a previous UAS report indicates the patient was totally dependent for all instrumental activities of daily living (IADLs). The patient was totally dependent or needed maximal assistance for all activities of daily living (ADLs), except eating (limited assistance). He could no longer walk, and was transported in his home by wheelchair, propelled by caregivers. As per New York State (NYS) regulations for 24 hour personal care services, when the frequency of the patient's need for assistance does not allow an aide to have 5 uninterrupted hours of sleep per day, then continuous services, i.e. split shift, are indicated. Reports from the patient's son indicate worsening incontinence and the need for diaper changes every 2 hours. The insurer's care manager notes include the son's report of limited sleep for the live-in aide. It does not appear the patient's nighttime care needs meet criteria for a live-in aide. The only way to have a more objective assessment of the patient's nighttime care needs is to obtain a recorded activity log of the patient's care needs at night. Even though the son did not include a detailed patient activity record, his comments regarding the frequency of the patient's care needs and frequency of aide services at night cannot be dismissed. Regarding possibility of sleep at other times of the day; daytime activities include housekeeping tasks, meals, routine ADLs plus toileting and incontinence care throughout the day; and so 5 hours of uninterrupted sleep during the day does not appear as a realistic option for a live-in aide. 

Considering the patient's medical history and functional impairment, it is medically necessary and in the patient's best interest for the patient to have a caregiver provide assistance for all routine ADLs and IADLs; unscheduled ADLs that occur during the day and night; and a scheduled plan for change of position for pressure relief. Considering the patient's son is requesting 24 hours spilt shift PCA services, it is reasonable to conclude that he is not able to provide 5 uninterrupted hours of assistance on a daily basis to allow the aide to sleep. Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services. When informal caregivers are unable to provide necessary assistance on a consistent basis, then personal care services are indicated to provide assistance with all daily activities when needed. 

The patient's physical and cognitive status has declined and his care needs have increased; specifically, incontinence frequency has increased and so he needs more frequent incontinence care. The patient has an advanced neurologic disorder. It is expected that his daily care needs will continue at a high level. The available records identify serious concerns about the frequency of the patient's care needs at night and insufficient sleep for the live-in aide; therefore, at this time, PCA continuous services (i.e. split shift) are indicated. 

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

The carrier's denial of coverage for PCA services 24 hours per day (split shift) is overturned. The medical necessity is substantiated.