Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, hyperlipidemia, atrial fibrillation, permanent pacemaker for complete heart block

Treatment: Personal care aide

The insurer is denied coverage for personal care aide. 

The denial is reversed. 

The patient is a female with hypertension, hyperlipidemia, atrial fibrillation, permanent pacemaker for complete heart block and extensive medical history associated with substantial functional impairment. She lives alone. She needs assistance for all daily activities. The patient's symptoms and functional impairment presents various health and safety risks. The UAS indicates the patient has unsteady gait and needs extensive (weight-bearing) assistance with walking. She also needs assistance with transfers from toilet and chair (UAS reports patient has difficulty standing up unassisted). The patient had some recent falls; one was specifically noted to occur when the patient was alone, she could not call for help until the aide returned in the morning. The patient has multiple risk factors for falls including: unsteady gait, poor vision, impaired balance, cognitive impairment, incontinence advanced age, h/o falls. Falls in older people are associated with increased risk of serious injuries (e.g. fractures, head trauma), substantial morbidity and increased risk of death. Even without a serious injury, a fall can result in pain and further decline of mobility. The patient's plan of care needs to address fall prevention. For a person with impaired mobility, poor vision and cognitive impairment, providing assistance with mobility-related ADLs can help prevent falls and other accidents. .  

During the night, it is unrealistic to expect the patient to remember to turn and reposition herself on a regular basis, especially with cognitive/memory impairment. The records provided for review (UAS, daughter and physicians letters/notes) indicate the patient has substantial functional impairment associated with multiple medical conditions. It is medically necessary for the patient to have a caregiver present during day and night hours to provide assistance with all daily activities, including ADLs that occur during the day and night; i.e. toileting, incontinence care, bed mobility/repositioning, transfers/walking. 

The patient's physical and cognitive impairments place her at high risk for adverse health and safety events (e.g. falls, skin injury, dehydration).  The patient's daughters are the only caregivers identified in the records. They provide care on weekends, but they work fulltime, and may have other responsibilities. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. When informal caregivers cannot provide care on a consistent basis, then personal care services are indicated to provide the necessary assistance with daily activities.

 Unless there are additional arrangements with informal caregivers for nighttime care, the patient will still be alone for 14 hours through the evening and night. The maximum number of hours that can be recommended from this review is limited by the number of hours requested, which in this case is 70 hours per week.  If informal caregivers can provide adequate care at night, then PCA 70 hours per week is satisfactory. If informal caregivers are not providing assistance with ADLs at night then reassessment will need to determine how nighttime assistance can be provided to meet the patient's care needs.

Personal Care Aide services, 7 days per week, 10 hours per day, 70 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Aide services, 7 days per week, 10 hours per day, 70 hours per week is substantiated.  The insurer's denial is reversed.