Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Coronary Heart Disease

Treatment: Increase the personal care aide hours to 7 days a week, 2- 12 hours a week (Split- Shift)

The insurer denied the increase the personal care aide hours to 7 days a week, 2- 12 hours a week (Split- Shift).

The denial was overturned.

This is a female patient with a history of coronary heart disease, hypertension, heart failure, hyperlipidemia, bladder cancer, colon cancer, hypothyroidism, phobic, anxiety disorder, insomnia, urinary incontinence, fecal smearing, dizziness, history of falls, muscle weakness, osteoarthritis, difficulty walking, hearing loss, macular degeneration, and constipation. She lives alone and needs substantial assistance with all daily activities. She has been receiving personal care aide (PCA) services 12 hours per day, 7 days per week.

Dizziness/vertigo: Dizziness has various possible causes and is a common symptom in older people. The specific cause may be difficult to identify, and there may be more than one contributing factor. The UAS indicates the patient has frequent dizziness. She has a diagnosis of vertigo, which appears to be associated at times with nausea; meclizine is taken prn. It was also noted the patient feels dizzy when she sits up in bed. Nighttime dizziness, especially when getting up from bed may be due to orthostatic changes, which is common in the elderly. Various medications can cause dizziness (e.g. antihypertensive drugs). Dizziness is a significant risk factor for falls.

The patient is at high risk for falls. Her mobility is impaired, and is further complicated by impaired judgment/decision making. The patient's fall risk factors include: arthritis, chronic pain, unsteady gait, dizziness, incontinence, advanced age, cognitive impairment, history of falls, use of medications associated with falls (e.g. antihypertensive drugs, benzodiazepine). When elderly people fall, there is greater risk of serious injury (e.g. fractures, head trauma) increased morbidity, and increased risk of death.

Dementia is associated with progressive loss of functional ability for daily activities. IADLs are usually affected before ADLs, as IADLs require a higher level of cognitive function. Cognitive impairment is probably a significant factor in the patient's dependence on caregivers for IADLs. Memory deficits, impaired judgment, and poor safety awareness can also affect the patient's ability with ADLs.

As per NYS regulations for live-in services, in order to qualify for a live-in aide, the patient's need for assistance should be sufficiently infrequent to allow the aide to have 5 uninterrupted hours of sleep within the 8 hour sleep period per day. The letter from the community friend noted the patient needs diaper change every two hours; but there are no detailed nighttime activity logs provided for review. The UAS indicates the patient does not sleep well. Due to dementia, her behavior is unpredictable. She is at risk for getting out of bed at night. Considering the patient's need for assistance with toileting and incontinence, her risk for falls if she tries to
get out of bed unassisted, and the need for repositioning for pressure relief periodically through the night, it appears less likely that an aide would consistently have 5 hours of uninterrupted hours of sleep each day.
It appears to be in the patient's best interest to provide PCA continuous services (i.e. split shift) to ensure that a caregiver is available to provide care when needed throughout the day and night.

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

Based on the above, the request to increase the personal care aide hours to 7 days a week, 2- 12 hours a week (Split- Shift), is substantiated. The denial was overturned.