Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, Chronic obstructive pulmonary disease, Primary generalized arthritis. 

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week. 

The insurer denied coverage for PCA Level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week. 

The denial is overturned. 

This is a male patient who receives hospice care at home. He has been diagnosed with dementia and chronic obstructive pulmonary disease (COPD). He was hospitalized for pneumonia, dehydration and non-ST elevated myocardial infarction (NSTEMI) resulting in further functional decline. The patient is receiving personal care aide (PCA) services 12 hours per day, 7 days per week. His daughter requested an increase of PCA services to 24 hours split shift which was denied by the insurer. 

The patient is totally dependent on caregiver support for all instrumental activities of daily living (IADLs) and activities of daily living (ADLs). The patient has several medical conditions identified in his Uniform Assessment System (UAS) and hospice physician's letter that most likely contribute to the patient's poor current functional status. 

The patient's decision making capacity for daily tasks is consistently poor or unsafe. It is likely that this decline is associated with the patient's recent hospitalization due to acute illness. The patient has short term and procedural memory impairment, which affects his ability to perform various daily activities. The patient has pain and stiffness which affects his ability to perform ADLs and household related tasks. The patient's COPD appears to be at an advanced stage, and is noted as one of the hospice diagnoses. The patient also has dyspnea with minimal exertion. He is on continuous oxygen and uses bronchodilators via nebulizer. Additionally, he is completely incontinent of bladder and bowel and is dependent on caregivers for incontinence care. The combined effects of chronic pain, dyspnea, weakness and fatigue on the patient's physical function, plus cognitive deficits that limit his ability to remember and process information needed for daily activities, appear to have resulted in severe functional impairment, requiring total assistance from caregivers. 

It does not appear that there are informal caregivers who can provide the necessary ADL care to the patient for extended periods of time on a daily basis. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. Without adequate and reliable assistance from informal caregivers, then personal care services are indicated to provide assistance with daily activities when needed throughout the day and night. 24 hour PCA services include live-in and continuous services. As per NYS regulations for personal care services, if the patient's care needs are sufficiently infrequent to allow an aide to have 5 uninterrupted hours of sleep per day, then live-in services are indicated. If the frequency for assistance does not allow an aide to have 5 uninterrupted hours of sleep per day, then continuous services are necessary. 

It is medically necessary and in the best interest of the patient to provide continuous personal care services, i.e. split shift, to ensure timely assistance for incontinence care and bed mobility/repositioning throughout the day and night. 

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

The medical necessity for PCA Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - 168 hours per week is substantiated. The insurer's denial is overturned.