Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Personal Care Aide Level 2: 8 hours per day, 7 days per week (split shift) for a total of 168 hours per week

The insurer denied the Personal Care Aide Level 2: 8 hours per day, 7 days per week (split shift) for a total of 168 hours per week. The denial was reversed.   

This is an elderly female patient with a history of hypertension, hyperlipidemia, cerebral infarction, systolic heart failure, coronary heart disease, hypothyroidism, anxiety, depression, dementia, urinary incontinence, osteoarthritis, and muscle spasm. It was reported that the patient lives alone and had a personal care aid 56 hours per week. Documentation reports that patient requires high level of assistance with most of her activities of daily living (ADLs). She is able to ambulate with a rolling walker with contact guard assistance. She has poor safety awareness and experiences confusion during tasks. 

With current PCA hours, the patient is alone for 16 hours per day.  This raises several questions.  It is not known whether the aide provides all evening care prior to leaving each day (i.e. dinner, evening hygiene, toileting, change of clothes, helps patient to bed).  If this is done, does the patient stay in bed until the aide returns the next day; or does she try to get out of bed for toileting or any other reason during the night.  If she tries to get out of bed, then she is at high risk for falls.  If she stays in bed all night, it is likely she will have wet, soiled diapers by the morning.  If the aide does not provide all evening care prior to leaving, it is not clear how the patient manages all these activities alone, as the UAS indicates the patient needs assistance for all these activities.  The nursing home notes indicate patient had episodes of confusion and agitation.  For a person with dementia, nighttime behavior is often unpredictable, and so a caregiver is needed to provide assistance for mobility related ADLs during the night as well as the daytime.

Based on the patient's medical conditions and functional status it is medically necessary for the patient to have a caregiver throughout the day and night to provide assistance for ADLs that occur at unscheduled and unpredictable times of the day and night.  For a patient with mobility problems and significantly impaired memory and decision making capacity, the risk for falls/accidents is high.  In addition, the patient needs extensive assistance with toileting and incontinence care, which cannot be adequately managed when the patient is alone. 

The patient has 2 informal caregivers noted in the UAS.  Considering the daughter requested 24 hour PCA services, it is reasonable to conclude that there are no informal caregivers who can provide the patient with assistance for ADLs during nighttime hours on a consistent basis. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  Without informal caregivers who can provide assistance consistently and for the time periods needed, then PCA services are medically necessary to assist patient with IADLs and ADLs, including ADLs that occur at unscheduled times throughout the day and night (i.e. ambulation, transfers, toileting/incontinence care). 

Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift) - total of 168 hours per week is medically necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for the requested Personal Care Aide Level 2: 8 hours per day, 7 days per week (split shift) for a total of 168 hours per week is reversed.  The medical necessity is substantiated.