Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes mellitus; Heart disease; Osteoarthritis

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

The insurer denied coverage for Personal Care Aide (PCA) Services of 7 days a week, 2-12 hours a day (split-shift) (168 hours per week).

The denial is upheld. 

The patient is a female with a history of type 2 diabetes mellitus, coronary heart disease, heart failure, atherosclerotic heart disease, unspecified atrial fibrillation, hypertension, hyperlipidemia, depression, osteoarthritis and a healed fracture.  Per the New York State Department of Health's Uniform Assessment System the daughter stated her mother has periods of forgetfulness and confusion. The patient was unable to participate during the assessment.  The patient has been hospitalized for hypoglycemia.  The patient's change in activities of daily living status compared to 90 days ago has declined, and her overall self-sufficiency has deteriorated.  The patient is under hospice / palliative care and is bed bound. She is only on pain medication. She has had a fall. 

Needs are: Total dependence for meal preparation, ordinary housework, stairs, shopping, transportation, bathing, locomotion and toilet use; Maximal assistance for managing finances, phone use, personal hygiene and dressing her upper and lower body; Extensive Assistance for managing medications, equipment management, bed mobility and eating; Cognition: There is mild-moderate impairment; Continence: The patient has an indwelling catheter for bladder control, and she is frequently bowel incontinent.

An increase to personal care aide (PCA) services of 7 days a week, 2-12 hours a day (split-shift) (168 hours per week) is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 notes:

"(a) Definitions and scope of services.

***(2) Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep....4) Live-in 24-hour personal care services means the provision of care by one personal care aide for a patient who, because of the patient's medical condition, needs assistance during a calendar day with toileting, walking, transferring, turning and positioning, or feeding and whose need for assistance is sufficiently infrequent that a live-in 24-hour personal care aide would be likely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.

The patient is on hospice/palliative care for congestive heart failure (CHF). She is bedbound and has an indwelling Foley. She needs extensive assistance or is dependent for ADLs. There are no scheduled nighttime tasks supported in the submitted documentation. The frequency of nighttime needs would be sporadic, related to bowel incontinence. An aide could be expected to get 5 hours of uninterrupted sleep. 

The health plan acted 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) Services of 7 days a week, 2-12 hours a day (split-shift) (168 hours per week) is upheld. Medical necessity is not substantiated.