Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment; osteoarthritis

Treatment: Personal care assistance, 7 days per week, 24 hours (split shift), total 168 hours per week. The insurer denied coverage for personal care assistance, 7 days per week, 24 hours (split shift), total 168 hours per week. The denial reversed.

This patient is a female who has several medical conditions contributing to functional decline and loss of independence. The family reports the patient now has fecal incontinence (in addition to urinary incontinence), wears pull-on diapers.  The patient's functional decline is worse.  She needs assistance with toilet use, shower, and feeding.  She communicates less; some days she stays in bed all day. She eats more than before, but has some weight loss.  On exam, the patient follows simple commands; states 1-2 words in response to questions; difficult to understand answers. Dementia affects the patient's ability to carry out activities of daily living (ADLs), and she has some behavioral disturbances.  She has a lot of needs that are not currently being met by HHA hours.  The patient would definitely benefit from increased HHA hours.

The patient has multiple reasons for needing caregiver assistance throughout the day and night. The need for toileting and incontinence care cannot be scheduled and cannot be expected to occur within a limited number of hours each day.  Regarding mobility, it appears the patient is not able to transfer or walk without assistance.  However, this does not mean that she may not attempt to get out of bed when she is alone.  The risk of her trying to get out of bed is increased due to dementia, as she may respond to internal cues or thoughts that are not based in reality.  The UAS indicates she has history of wandering, and the physician reported behavioral disturbances.  If she attempts to get out of bed, a caregiver is needed to assist the patient; either to help her back to bed or assist her to safely get out of bed.  

The UAS indicates that the patient's daughter is the primary informal caregiver.  As per the UAS-ATSP, the granddaughter is an alternate caregiver, but the extent of her assistance is not clear.  The insurer's denial letter indicated a sister is involved, but it was reported in the insurer's letter that the sister cannot provide much assistance due to her own health.  Another concern is the physician's comment that the patient's "caretaker" (the person was not identified) is showing signs of caregiver burden.  Caregiver stress is a significant problem that can adversely affect the health and safety of both the caregiver and care recipient.  When signs of such stress are identified, it is in the best interest of all involved to find alternative solutions for care.

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  The patient's daughter is requesting 24 hour, split shift PCA services; and so it is reasonable to conclude that there are no informal caregivers who are able to provide the care the patient needs throughout the day and night.

When there are no informal caregivers who can provide care on a consistent basis and for the necessary amount of time, then it is medically necessary for personal care services to provide assistance for ADLs and IADLs.  In this case, the patient needs caregiver assistance for ADLs that occur on an unscheduled basis day and night (i.e. toileting, incontinence care, transfers, walking).

Personal care assistance services 7 days per week, 24 hours per day, split shift is approved.

The carrier's denial of coverage for personal care assistance, 7 days per week, 24 hours (split shift), total 168 hours per week is reversed.  The medical necessity is substantiated