Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia/cognitive impairment, Depression/anxiety, Osteoarthritis, Dyspnea, Obesity

Treatment: Personal Care Aide (PCA) services 10 hours per day, 7 days per week - total of 70 hours per week

The insurer denied coverage for Personal Care Aide (PCA) services 10 hours per day, 7 days per week - total of 70 hours per week.

The denial is overturned. 

This is a female patient who has extensive functional impairment associated with several medical conditions. The patient had a few hospitalizations in recent months, and it appears the patient stayed with the daughter for a while after hospital discharge, and now has returned to her home. The patient was receiving personal care aide (PCA) services 5 hours per day, 6 days per week. The patient (via designee) requested an increase of PCA services to 10 hours per day, 7 days per week, which was denied.  

The Uniform Assessment System (UAS) report indicates the patient is totally dependent for most instrumental activities of daily living (IADLs); except transportation (maximal assistance) and stairs and phone use (extensive assistance). The patient needs extensive or limited assistance for all activities of daily living (ADLs) except eating (independent setup help). The patient has several medical conditions that most likely are significant contributing factors to her functional impairment including dementia/cognitive impairment, depression/anxiety, osteoarthritis, dyspnea, obesity; and she had several acute medical problems in recent months, requiring hospitalization (rib fractures, hemopneumothorax, and pneumonia). 

Considering the patient's medical conditions and functional decline, it is medically necessary for a caregiver to be present to assist the patient with daily activities when needed throughout the day. The patient needs total assistance with meal preparation and clean-up. She needs extensive assistance with dressing, personal hygiene and toileting; and so a caregiver is needed for the evening meal and ADLs. The patient lives with her elderly husband. The insurer approved 8 hours and recommended splitting the hours to cover evening activities. However, if the hours are split, there will be hours during the day when the aide is not present. It appears 10 hours are needed to cover the day from morning until evening without interruption. This appear to indicate that the patient's husband is not able to provide the level of assistance needed for toileting, transfers and ambulation that will likely be needed during a mid-day break between PCA shifts.

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. The patient (via designee) is requesting PCA 10 hours per day; and so it is reasonable to conclude that there is no capable informal caregiver who can provide assistance to the patient from the morning through the day until evenings activities are completed.  When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide the patient with assistance for all necessary daily activities (IADLs and ADLs) when needed.

There is still a concern about the patient's nighttime ADLs (toileting, incontinence care, transfers, ambulation).  It is not known whether there are other informal caregiver plans in place.  

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 10 hours per day, 7 days per week - total of 70 hours per week is overturned. The medical necessity is substantiated.