Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease

Treatment: Personal care aide (PCA) service hours 7 days per week 2-12 hours a day, split shift services

The insurer denied coverage for personal care aide (PCA) service hours 7 days per week 2-12 hours a day, split shift services

The denial is overturned.

This is a patient who has substantial functional impairment associated with various medical conditions. The patient is dependent on caregivers for all daily activities. As per section A of the Uniform Assessment System (UAS), the patient's living arrangement is noted as "alone"; but the comments in section A are inconsistent, i.e., "member resides with their wife" followed by "member lives alone". In the final adverse determination letter the only family member identified as involved in the patient's care is their daughter; and in the UAS, the daughter is identified as the only informal helper (noting that the daughter does not live with patient). The patient primarily depends on personal care aide (PCA) services for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient was receiving PCA services 7 days per week, two 12-hour shifts per day (split shift). The insurer decided to reduce PCA services to 7 days per week, live-in. The patient (via designee) requested an appeal, which was denied. External appeal was requested.

The most recent UAS provided for review was done. The functional status report indicated the patient is totally dependent for all ADLs and IADLs. ADL report indicated walking and transfer toilet did not occur during entire period. ADL and IADL status is unchanged from the previous UAS. As per the UAS, patient was reported as bedbound; no out of bed activity was reported.

As per NYS regulations for personal care services, 24-hour care can be provided as live-in services or continuous services. In order to qualify for live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep within an 8-hour sleep period daily. If the patient's care needs are of such frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services (split shift) are indicated. The issue of this review is to determine if the patient's care needs can be met with live-in services or if continuous services are necessary.

With no reported improvement in the patient's medical condition and/or functional status, and no reported change of informal support/services, the criteria for reducing PCA services have not been met.

The patient's personal care needs include routine tasks (housekeeping, meal preparation, medications, bathing, dressing, personal hygiene), plus unscheduled and/or recurring tasks (e.g., incontinence care, feeding, repositioning, as needed pain medication). Considering the patient's medical history, functional status (total dependence for all ADLs/IADLs), and the patient's care needs day and night, there does not appear to be a consistent time period each day when a live-in aide can expect to have 5 uninterrupted hours of sleep on a regular daily basis. Therefore, PCA 24 hours per day continuous services (split shift) are indicated. 

Recommendation is given to approve Personal Care Aide services 7 days per week, two 12-hour shifts per day (split shift).

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care aide (PCA) service hours 7 days per week 2-12 hours a day, split shift is substantiated.