Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive Multiple Sclerosis (MS)

Treatment: Personal Care Aide (PCA) Level 2; 24 hours per day - Live-in per diem - 7 day(s) per week

The insurer denied Personal Care Aide (PCA) Level 2; 24 hours per day - Live-in per diem - 7 day(s) per week. The denial was reversed.   

This is a female patient with a medical history of severe secondary progressive multiple sclerosis. Her medical condition has deteriorated making her almost a quadriplegic requiring further care at night with turning in the bed, changing soiled diapers and assisting with dressing. She is in need of assistance with all of her activities of daily living (ADLs).  She had requested an increase in personal care assistance (PCA) from 9 hours per day 7 days a week to 24 hours liv-in PCA due to the severity in her medical deterioration.  

Secondary progressive multiple sclerosis is the late stage of relapsing-remitting multiple sclerosis and results in progressive neurologic impairment and disability.  Treatment options for this stage of the disease are less effective than for relapsing-remitting MS. Based on the UAS and the Neurologist's letter, it appears the patient has minimal physical capacity for any activities.  She is totally dependent on caregiver assistance for IADLs and ADLs.  She does not walk, needs wheelchair for locomotion; transfers require Hoyer lift, and she needs total assistance for all personal care needs.  The effects of MS extend beyond loss of mobility, and include other problems such as incontinence and pain. 

The patient is totally dependent on caregiver assistance for bed mobility.  Whether the patient is in a chair or in bed, she cannot move independently. Immobility is significant risk factors for pressure ulcers.  Providing some type of pressure relief cushion on the chair and pressure relief mattress on the bed is indicated.  However, this does not eliminate the need for repositioning. The patient does not intermittently get up and walk to relieve pressure; and she cannot shift to another position without help.  Caregiver assistance is necessary to reposition the patient at regular intervals throughout the day and night in order to relieve pressure from body surfaces resting on the chair or bed.  The occurrence of a pressure ulcer for this patient can result in significant adverse effects and complications.  Pressure ulcers cause pain, limit out of bed time, and is a source of infection/sepsis.  Turning and repositioning the patient is a necessary part of the care plan.  The patient should not remain in the same position throughout the night.

As per NYS regulations for live-in personal care aides, a person's care needs must be of such frequency that an aide can expect to have at least 5 uninterrupted hours of sleep per day.  It is not clear whether the patient's nighttime ADL needs will allow the aide to obtain the necessary hours of sleep.  The recommendation from this review cannot exceed the amount of services requested; and so PCA 24 hours live-in is approved.  Whether this plan of care is sufficient to best serve the needs of the patient and provide adequate rest for the aide; or if additional services (split shift) are necessary will be determined by re-assessment.

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

The carrier's denial of coverage for Personal Care Aide (PCA) Level 2; 24 hours per day - Live-in per diem - 7 days(s) per week is reversed.  The medical necessity is substantiated.