Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Borderline Intellectual Functioning; dizziness; difficulty bending forward, limited ROM 
 
Treatment: Increase in Personal Care Assistance (PCA) services from 28 to 56 hours.

The insurer denied the increase in Personal Care Assistance (PCA) services from 28 to 56 hours. The denial was reversed.   
This is an elderly male patient with a medical history of coronary artery disease, hypothyroidism, anemia, seizure disorder, chronic obstructive pulmonary disease, vertigo, constipated by delayed colonic transit, class ll severe obesity, cirrhosis, hypertension, hyperlipidemia, type 2 diabetes mellitus and asthma. A capacity evaluation was performed in early 2019 while being treated in a subacute rehabilitation facility. It was determined that he was not competent with the possibility of a learning disability or neurodevelopmental disorder.  It was reported that the patient had a below average intellect, insight and judgment limited. It was reported that the patient lives alone with no support system. Due to his extensive medical history resulting in various functional limitations he has required personal care assistance. He is seeking an increase in his personal care assistance.

The patient's functional status as reported in the late 2019 UAS indicates patient needs maximal assistance for IADLs; except for phone use (limited assistance).  For ADLs, extensive assistance is needed for bathing and lower body dressing, with limited assistance for hygiene, locomotion and toileting. There are various restrictions to mobility noted including: inability to stand for prolonged periods of time, dizziness; difficulty bending forward, limited ROM, fatigue to the extent that he cannot finish daily activities. It is noted that the patient ambulates with rollator but has difficulty. It is apparent that the patient has functional limitations that impose a substantial burden on his ability to perform most daily tasks. 

The patient has a complex medical history with problems that may stabilize for a while but are at risk for decompensation (e.g. heart failure, liver failure, asthma/COPD). It appears there may have been recent acute episodes requiring change in treatment. The patient's current status is not known, but it is reasonable to consider that the combined effect of chronic symptoms and limitations to mobility plus periodic exacerbations of chronic diseases result in decreased energy and endurance to perform daily tasks. With 4 hours per day of assistance, the patient is alone for most of the day when he is out of bed and needs to move around his home and manage various tasks. The patient needs maximal assistance for all household tasks, so he is very limited in what he can do when he is alone. He needs assistance for walking and toileting which occurs throughout the day. The patient is at high risk for medical and functional decline. In older people, the combined effect of multiple co-morbidities increases risk of adverse outcomes. As a result of the patient's symptoms and functional limitations from his health problems, it is medically necessary and in the patient's best interest to provide additional assistance to help him through daytime hours when he is most active and in need of assistance, including ADLs (ambulation, toileting) and household tasks. The patient has no informal caregiver support in the community. Therefore, it is medically necessary to provide additional assistance through PCA services.

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

Based on the above, the medical necessity for the denial of coverage for the request for an increase in Personal Care Assistance Services from 28 to 56 hours per week is substantiated. The insurer's denial is reversed.