Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD).

Treatment: PCA (personal care assistance) services for 7 days per week, 24 hours per day (split shift) personal care.

The insurer denied coverage for PCA services for 7 days per week, 24 hours per day (split shift) personal care.

The denial is overturned.

This is the case of a female with extensive medical history associated with substantial functional impairment. She needs assistance with instrumental activities of daily living (IADLs) and activities of daily living (ADLs). She lives with her husband. The patient receives personal care assistance (PCA) services as 70 hours per week designated for her use, plus shared services of 14 hours per week with her husband (mutual case). The New York Uniform Assessment System (UAS-NY) indicates the husband provides some informal help to the patient when PCA is not present, but it appears the level of assistance is limited due to his own health problems. No other informal caregivers are identified in the UAS (Uniform Assessment System). Request was made for increase of PCA services to 24 hours per day, split shift, which was denied. 

The patient's cognitive status as described in the UAS indicates significant impairment. Decision making for daily tasks is reported as consistently poor/unsafe with cues and supervision needed at all times. She was oriented to person and place. She has short term and procedural memory impairment. In the UAS, it was also noted patient had episodes of verbal abuse and resisting care at times. There is no specific diagnosis in the records except age related cognitive decline (in UAS). The records also include diagnosis of depression which appears to be a long-standing problem. The most recent medication list includes Paxil. Depression is often associated with cognitive impairment in older people. The patient's cognitive impairment is significant to the extent that it likely affects her ability with IADLs (which are generally affected before ADLs, as IADLs require a higher level of cognitive function). The patient needs extensive or maximal assistance with all IADLs. Regarding ADLs, the patient has significant physical impairment affecting ADL function, and it is unclear to what extent cognitive impairment affects her ability with ADLs. However, with poor decision-making ability, and probably impaired safety awareness, there is increased risk of falls and accidents when performing ADLs.

It is reasonable to conclude there are no informal caregivers who are able to provide care for extended periods of time each day on a regular basis. The extent of the husband's assistance is not fully described, but it is reported he has health problems and is receiving PCA services as a mutual case with his wife. For the type of care the patient needs for ADLs (mostly weight-bearing assistance), the husband does not appear to be a safe provider (for him and the patient) for this level of care. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance when needed for daily activities, including ADLs that occur at unscheduled and recurring times of the day and night.

The nighttime log indicated care was needed for incontinence and repositioning with intervals from 1 12 hours to 3 12 hours. As per NYS regulations for live-in services, a live-in aide needs to have 8 hours of sleep per day, including 5 uninterrupted hours of sleep. The frequency of the patient's care needs do not appear compatible with the service time of a live-in aide. The plan that would best serve the patient's care needs is PCA 24 hours per day, split shift services.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. Personal Care Assistance services 7 days per week, 24 hours per day (split shift) is medically necessary.

The insurer's denial of coverage for personal care assistance (PCA) services for 7 days per week, 24 hours per day (split shift) personal care is overturned. Medical Necessity is substantiated.