Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Coronary Artery Disease 
Treatment: Personal Care Assistance (PCA), Level ll, 24 hours per day,
7 days per week (split-shift); total 168 hours per week 

The insurer denied the Personal Care Assistance (PCA), Level ll, 24 hours per day,
7 days per week (split-shift); total 168 hours per week. 

The denial was overturned. 

This is a female patient who was hospitalized cerebrovascular accident and was then transferred to a nursing home (NH). She has a history of coronary heart disease, type 2 diabetes mellitus, hypercholesterolemia, hypertension, cerebrovascular disease, encephalopathy, Alzheimer's disease, anxiety, depression, osteoarthritis, pain, gait abnormality, functional urinary incontinence, allergic rhinitis, asthma, GERD, constipation, irritable bowel syndrome, dizziness, glaucoma, hearing loss. She received physical therapy several times per week as of early 2020. The family attempted to arrange for personal care services for the patient so that she could return home. It was reported that the patient lived in an apartment with her son. She has moderately impaired decision making capacity and memory impairment it appears the patient was in the range of moderate cognitive impairment. She needed substantial assistance for household tasks. Her son managed her finances and medications. For ADLs, she needed extensive assistance for bathing, dressing and toileting (she also had frequent urinary
incontinence). She was ambulatory with a cane and limited assistance. She was also
independent with eating and bed mobility. 

The patient needed 2 person assist for transfers. She was taking multiple medications and could not self-administer medications. She needed to monitor her blood glucose which she was not able to manage herself. The patient needs safety supervision. 

The patient needs weight-bearing assistance for all mobility (including transfers), toileting/incontinence care and bed mobility. If the patient needs toileting during the night, she will need substantial assistance to use the toilet or a commode. If she is incontinent she needs prompt incontinence care to prevent incontinence associated skin damage, including dermatitis, fungal infection. Incontinence also increases risk of pressure ulcers. The patient needs extensive assistance with bed mobility, and it is unlikely she will be able to effectively reposition herself through the night to prevent prolonged pressure on one area. The insurer noted in the final denial letter that there is no medical requirement for frequent turning and positioning or changing of incontinence products at night in the absence of decubitus ulcers. As immobility and incontinence are among the primary risk factors for development of pressure ulcers. It is not consistent with accepted standards of care to wait until a person develops a pressure ulcer to implement nighttime incontinence care and a repositioning schedule. For frail, elderly people, pressure relief and prompt cleaning after incontinence are necessary interventions for pressure ulcer prevention plan of care. It is noted that the in fact, the UAS nurse instructed the family "to change incontinence supplies frequently to prevent skin breakdown". Pressure ulcers are a source of pain and can result in infection/sepsis. The patient is diabetic, and prevention of skin wounds and any type of infection should be a priority. 

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. The son who will be living with the patient is available for assistance when needed for ADLs, medication administration, glucose monitoring. 

Based on the above, the medical necessity for Personal Care Assistance (PCA), Level ll, 24 hours per day, 7 days per week (split-shift); total 168 hours per week is substantiated. The insurer's denial is overturned.