Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, gait abnormality, diabetes, neuropathy, hypertension, and incontinence

Treatment: Personal care aide (PCA) hours for 7 days a week 24 hours a day (live in)

The insurer denied coverage for personal care aide (PCA) hours for 7 days a week 24 hours a day (live in)

The denial is overturned

This is an elderly female with a history of dementia, gait abnormality, diabetes, gastroesophageal reflux disease, reactive airway disease, neuropathy, hyperlipidemia, hypertension, and incontinence. The patient's cognition is severely impaired. She requires total dependence with meal preparation, phone use, and ordinary housework. The patient is frequently incontinent and wears pullups. She had one recent fall with minor injuries. 

The request for increase of PCA services is for 24 hours per day live-in. As per New York State (NYS) regulations for personal care services, 24-hour care can be provided as live-in services or continuous services (split shift). Managed Long-Term Care (MLTC) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. 

The most recent Uniform Assessment System (UAS) indicates she is totally dependent for most instrumental activities of daily living (IADLs). It appears that her cognitive impairment is a substantial cause of her inability to perform IADLs without assistance from caregivers. For activities of daily living (ADLs), the patient is totally dependent; limited assistance for walking, locomotion, transfer toilet, and bed mobility. 

The records indicate the patient has advanced dementia; diagnosis of Alzheimer's disease is noted in the UAS. The UAS includes a description of the patient's cognition and decision-making ability for daily tasks is severely impaired. She is oriented to self only and has severe memory impairment. Communication is severely impaired. She is unable to make her needs known. One example reported in the UAS is the patient's inappropriate toileting behavior; the patient rips off her diapers, with episodes of defecating and urinating on the floor, using curtains to wipe herself. This type of behavior is not unusual with advanced dementia, as the person no longer remembers or understands how to use the toilet and appropriate cleaning methods.

It is reported the patient has behavioral problems associated with dementia. The UAS indicates the patient wanders around the house at night (safety locks are in place); she has episodes of verbal and physical abuse towards others; socially inappropriate behavior (e.g., taking her clothes off); often resists care. It is noted that she has delusions and hallucinations. 

Based on the patient's medical history and functional status, it is medically necessary for the patient to have assistance with all daily activities. She has limited informal help, and so she is primarily dependent on personal care services for ADLs and IADLs. This level of caregiver assistance is necessary to help ensure adequate food and fluid intake, decrease risk of complications from inadequate toileting/incontinence care (e.g., skin damage, UTI [urinary tract infection]), and help decrease occurrence of falls and injury. 

With live-in services, the patient will benefit from additional ADL assistance during the evening/night hours that is not available to her with her current services (PCA 10 hours per day). The live-in aide will be able to help identify the patient's evening and nighttime ADL needs. Re-assessment will determine whether the patient's care needs are sufficiently met with live-in services or if a different plan is needed.

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

The insurer's denial of coverage for personal care aide hours for 7 days a week 24 hours a day (live-in) is overturned. Medical necessity is substantiated.