Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, depression, and osteoarthritis

Treatment: Personal care aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week

The insurer denied coverage for personal care aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week

The denial is overturned

 
This elderly patient has physical and cognitive impairment associated with several medical conditions and needs assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The Uniform Assessment System (UAS) identifies the patient's daughter as the only informal helper. The patient relies mostly on personal care aide (PCA) services for assistance with daily activities. The patient was receiving PCA 49 hours per week (7 hours per day). The daughter requested (as patient designee) an increase of PCA services to 84 hours per week (12 hours per day), which was denied.

As per the UAS, the patient needs maximal assistance with toilet transfer and toilet use (the latter includes incontinence care). This is consistent with report of weakness and back, knee, shoulder and hand pain. The patient also needs maximal assistance to reach the bathroom (either walking or by wheelchair), or with transfer to the commode. 

The patient has poor mobility which appears to be due to pain and weakness. She needs maximal assistance for transfers and walking. The UAS reports she can walk less than 15 ft (feet) (with assistance), then needs to rest. The prior UAS reported 3 falls the previous month when the patient was alone. The more recent UAS did not report recent falls. It is unclear whether the patient still attempts to get off the bed when she is alone. She may be sleeping better at night (physician noted medication was helping), and so getting out of bed and the occurrence of falls at night may be controlled. However, during the day when she is awake, she may want to get up from bed. Her ability to move in bed may be so limited now that getting out of bed unassisted may no longer be possible; but if she can still move to the edge of the bed and try to get up unassisted, this is a high-risk situation for falls. Another concern is the patient's use of clopidogrel which is associated with a higher mortality and complication rate for fall trauma in elderly people. When older people fall, there is higher risk of serious injuries (fractures, head trauma), substantial morbidity, and increased risk of death. The patient is physically unable to safely transfer and walk, but she does not have the cognitive awareness to realize her limitations; and so, she needs ADL assistance for mobility if she tries to get off the bed. 

Considering the patient's medical history and functional status (as noted in UAS, physician's office note, hospital PT (physical therapy) note), it is medically necessary, and in the patient's best interest to have assistance for all daily activities when needed throughout the day. This includes household tasks; meal preparation; medications; routine ADLs (bathing; personal hygiene, dressing, eating); and ADLs that occur at unscheduled and recurring times of the day (toileting, incontinence care, transfer, walking, wheelchair mobility, repositioning). Assistance is necessary for proper and safe completion of all ADLs/IADLs; ensure adequate food and fluid intake; decrease risk of complications due to incontinence (skin damage, infection); help decrease occurrence of falls/injury.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week is substantiated.