Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, Cerebral Vascular Accident (CVA).

Treatment: Personal Care Assistance services, Level ll, 24 hours per day split shift services, 7 days per week (Monday through Sunday).

The insurer denied the Personal Care Assistance services, Level ll, 24 hours per day split shift services, 7 days per week (Monday through Sunday).

The denial was overturned.

This is a female patient with a medical history of interstitial lung disease, pulmonary embolism, history of deep vein thrombosis (DVT), coronary artery disease (CAD), hypertension, hyperlipidemia, diastolic heart failure, type 2 diabetes mellitus, with diabetic nephropathy, Chronic kidney disease (CKD) stage III, hypothyroid, gastroesophageal reflux disease (GERD), cerebral vascular accident (CVA), lumbar compression fracture, osteoporosis, lumbar back pain, spinal stenosis lumbar spine, osteoarthritis of knees, gait instability, tendonitis left rotator cuff, cervicalgia, schizoaffective disorder, depression, dysphagia, failure to thrive, obesity class 3, anemia, benign paroxysmal positional vertigo, Vit D deficiency. The patient lives alone but at the time the patient's daughter who lives in another state was staying with the patient. The patient receives personal care assistance (PCA) services 12 hours per day (84 hours per week). The patient was recently hospitalized and the daughter indicated her mother's condition has declined and requested increase of PCA services to 24 hours split shift, which was denied by the insurer.

Functional decline in the elderly is often the result of the cumulative and interactive effects of multiple chronic medical conditions; including effects and interactions of multiple medications. An acute illness will often result in further functional decline. If the acute event (e.g. infection) is self-limiting and resolves, some degree of lost function may be restored after a period of recovery and possibly rehabilitation. 

The patient has chronic pain from various sources including: arthritis (knees specifically noted), lumbar spinal stenosis, sciatica, lumbar compression fracture, left rotator cuff tendonitis, diabetic peripheral neuropathy (foot pain). The medication list includes opioid analgesics, acetaminophen, topical analgesics, gabapentin for neuropathic pain. The patient takes medication for pain at 1am to help her through the night (when daughter is not present, she calls her mother to remind her to take medication at night). Chronic pain is physically debilitating; and can also contribute to depression and anxiety.
The patient's mobility is severely impaired. At the time of the UAS, she could not walk more than a few feet during a transfer. Her apartment is reported as too small to accommodate a wheelchair, so she is transported in the apartment on her rollator. She needs weight-bearing assistance for transfers, including transfer on and off the toilet or commode. The fact that the patient has great difficulty getting out of bed does not necessarily mean she will not attempt to get out of bed. The physician reported a recent incident when the patient fell trying to transfer from bed to the commode at night and remained on the floor (soiled from incontinence) until the aide arrived in the morning. This is a high risk situation. The patient needs assistance to get out of bed; but she may either not fully understand or remember her limitations; or she may be so uncomfortable (e.g. if she needs to use the toilet, or she is wet/soiled from incontinence) that she tries to get out of bed to help herself, increasing her risk for falls at night. 

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 Personal Care Assistance services, Level ll, 24 hours per day split shift services, 7 days per week (Monday through Sunday) is substantiated.  The insurer's denial is overturned