Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, anxiety, foot drop, spinal stenosis, macular degeneration and incontinence. 

Treatment: Personal care aide (PCA) level 2 services of 10 hours per day, 7 days per week for a total of 70 hours per week. 

The insurer denied coverage for PCA level 2 services of 10 hours per day, 7 days per week for a total of 70 hours per week. 

The denial is overturned. 

The patient is an elderly female patient with a past medical history of Alzheimer's disease, anxiety, foot drop, spinal stenosis, macular degeneration and incontinence. The patient is totally dependent for meal preparation, ordinary housework, managing finances, managing medications, phone use, managing stairs, shopping, equipment management, bathing, bed mobility, eating, locomotion, toilet transfer and toilet use. The patient needs maximum assistance with transportation, personal hygiene and dressing her upper and lower body. An increase to personal care aide (PCA) level 2 services of 10 hours per day, 7 days per week for a total of 70 hours per week is being requested. 

The patient has deteriorated and her care needs require more time. Feeding her 3 meals requires 4 hours. In addition, all bathing, personal hygiene, toileting, dressing are done in her bed, and so more time is required for these tasks. Many of these tasks take place during the day and night. 

Regarding toileting, the Uniform Assessment System (UAS) includes report from the PCA indicating the patient no longer responds to urge and is incontinent of bladder and bowel. The patient is dependent on a caregiver for incontinence care. Incontinence products can provide protection for a period of time, but prompt cleaning and skin care after episodes of incontinence is necessary to prevent incontinence associated skin damage. 

The patient is at high risk for pressure ulcers due to several factors including: incontinence, severely impaired mobility, and possible nutritional impairment (low body mass index); the patient needs to be fed by her PCA over several hours. Advanced dementia is also associated with increased risk of pressure ulcers. 

The UAS indicates the patient is completely dependent on caregivers for all mobility, including bed mobility; and so it is necessary to have a caregiver present to reposition the patient on a regular basis throughout the day and night (in bed, wheelchair, recliner). If the patient has a pressure relief mattress on her bed, this is useful. 

As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary (either as direct assistance from informal caregivers or through paid services at the expense of informal caregivers). The family cannot provide sufficient hours of care through either paid services or informal care to fully supplement the current 7 PCA hours per day. It is medically necessary for the patient to have 24 hour caregiver services to accommodate the patient's recurring and unscheduled activities of daily living (ADLs) care needs throughout the day and night. However, the family is not requesting 24 hour PCA services. They are requesting PCA 10 hours per day, 7 days per week. When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance with ADLs and instrumental activities of daily living (IADLs) when needed. The family is requesting 10 hours of PCA services per day, with additional assistance provided by the family for the other hours of the day. 
 
The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 10 hours per day, 7 days per week for a total of 70 hours per week is overturned. Medical necessity is substantiated.