Diagnosis:
Central Nervous System/ Neuromuscular Disorder
Treatment:
Home Health Care
Health Plan:
Aetna Better Health of New York
Decision:
Overturned overturned
Appeal Type:
Medical necessity
Gender:
Female
Age Range:
80-89
Decision Year:
2022
Appeal Agent:
IPRO
Case Number:
202203-147871
Summary

Diagnosis: Alzheimer's dementia, hypertension, stage 3 chronic kidney disease (CKD), osteoarthritis (OA), asthma, and rectal adenocarcinoma. Treatment PCA (personal care aide) hours, 7 days per week 2-12 split shift (168 hours per week). The insurer denied coverage for PCA hours, 7 days per week 2-12 split shift (168 hours per week). The denial is overturned. This is a patient with multiple medical problems including Alzheimer's dementia, stroke and rectal adenocarcinoma. She lives alone in a 1-bedroom apartment. According to the treating physician's office visit note, "Patient's daughter had to resign from work to take care of mother for 2 years and needs to go back to work to support her own family. She will start working CDPAP (consumer directed personal assistance program) 10 hours for 2 days for patient and aide from agency for 5 days." The patient is receiving PCA services 7 days/week, 10 hours/day for a total of 70 hours. Under review is the request for increase in PCA hours to 7 days per week 2-12 split shift (168 hours per week). According to the Uniform Assessment System (UAS), the patient is totally dependent for activities of daily living including bathing, dressing, and personal hygiene. She is reportedly "bed bound" and totally dependent for bed mobility. Feeding is via an NG (nasogastric) tube. She is bowel and bladder incontinent. The patient is unable to verbally respond to questions or instructions. Cognition is described as "severely impaired." The patient's functional incapacity and dementia renders the current PCA services 7 days/week, 10 hours/day for a total of 70 hours, insufficient. The requested increase in PCA hours to 7 days per week 2-12 split shift (168 hours per week) is clinically appropriate; allowing the patient the ability to continue living safely at home. The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based). From a physical medicine and rehabilitation perspective, the requested increase in personal care aide (PCA) hours to 7 days per week 2-12 split shift (168 hours per week) is medically necessary for this patient. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for 7 days per week 2-12 split shift (168 hours per week is overturned. Medical Necessity is substantiated.

References

1) Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L. Repositioning for pressure ulcer prevention in adults. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD009958. DOI: 10.1002/14651858.CD009958.pub2. 2) Functional Decline in Older Adults, Am Fam Physician 2013 Sep 15; 88(6): 388-394. 3) Optimal management of incontinence-associated dermatitis in the elderly, Am J Clin Dermatol 2010; 11(3): 201-10. 4) Incontinence Associated Dermatitis, Characteristics and Relationship to Pressure Injury, Journal of Wound, Ostomy and Continence Nursing; 2018 Jan; 45(1): 63-67.