Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, atherosclerotic heart disease Anaplastic meningioma (grade III), headaches, insomnia, dizziness, unsteady gait, fatigue

Treatment: Personal care aide (PCA) level 2 services of 6 hours per day, 7 days per week for a total of 42 hours per week

The insurer denied coverage for personal care aide (PCA) level 2 services of 6 hours per day, 7 days per week for a total of 42 hours per week.

The denial is overturned.

The patient has an extensive medical history, including surgery for meningioma. The patient has various symptoms due to meningioma and other chronic medical conditions which contribute to patient's decreased functional ability to perform daily activities. The patient is married, but as per the patient advocate's letter, the husband does not currently live with the patient due to his work which is out of state. 

The most recent UAS (Uniform Assessment System) provided for review was done. The functional status report indicates patient needs maximal or extensive assistance for most IADLs (instrumental activities of daily living), except managing finances (limited assistance), managing medications (supervision), phone use (setup help). For ADLs (activities of daily living), the patient needs extensive assistance for bathing; limited assistance for most other ADLs, except personal hygiene and eating (setup help); bed mobility (independent).

The UAS indicates the patient has difficulty walking, unsteady gait, difficulty moving to standing position, all of which can be at least partly due to lower back and lower extremity pain. It was also noted she can raise her arms only halfway which can affect ADLs that depend on upper extremity function. The UAS includes multiple medications for pain management including meloxicam, diclofenac gel prn (as needed), lidocaine topical prn, acetaminophen prn. Considering the patient's short term memory loss, it would be safer for the patient to have a caregiver present when she needs to take medication prn for pain, to prevent excess dosing (e.g., if patient forgets when or if she recently used oral and/or topical treatment).

The UAS reports patient needs limited assistance with toilet transfer and toilet use. Limited assistance should not be considered as optional or inconsequential. Due to weakness, pain, poor balance, dizziness, the patient needs assistance for stability when transferring on/off the toilet. Considering the patient has multiple symptoms affecting her mobility, it is also likely there are times when symptoms are worse and she may need some weight-bearing assistance as well. It was noted the patient needs assistance with clothing adjustment after toileting. When she is alone this could present a problem, as she may not be able to safely bend down and pull up her pants, especially if she is dizzy, which could increase risk of falls.

Based on the information provided for review, the patient needs assistance with activities that occur at various routine and unscheduled times during the day, and the care plan needs to accommodate these care needs.  Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services.  The patient's daughter was providing up to 3 hours of care per day (with PCA 4 hours per day, the patient was receiving 7 hours of services per day); but the daughter's job now restricts her time for caregiver responsibilities. 

Personal Care Aide services Level 2: 7 hours per day, 6 days per week; total of 42 hours per week is medically necessary. 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 Personal Care Aide (PCA) Level 2 Services of 6 hours per day, 7 days per week for a total of 42 hours per week is substantiated. The insurer's denial overturned.