Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes, deep vein thrombosis (DVT), pulmonary embolism (PE), hypercholesterolemia, osteoporosis, and dementia

Treatment: Personal care aide (PCA) hours 7 days a week 12 hours a day, 84 hours a week

The insurer denied coverage for PCA hours 7 days a week 12 hours a day, 84 hours a week

The denial is overturned

This patient has extensive medical history associated with functional decline for daily activities. The patient lives alone. She receives some informal help from her family, but she mostly depends on PCA services for help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient was receiving PCA services 35 hours per week. She was hospitalized twice recently; discharged home after the second admission. Following her return home, the patient requested increase of PCA services to 84 hours per week, which was denied; but the insurer increased PCA services to 56 hours per week. An external appeal was requested for PCA services 84 hours per week.

The most recent Uniform Assessment System (UAS) report was reviewed. The functional status report for IADLs indicates patient is totally dependent for meal preparation, ordinary housework, transportation; she needed maximal assistance for managing finances and medications, stairs, shopping; extensive assistance for phone use. For ADLs, the patient was totally dependent for locomotion; she needed maximal assistance for bathing, dressing lower body, toilet use; extensive assistance for personal hygiene, dressing upper body, transfer toilet, walking, bed mobility; limited assistance for eating. Comparison of the most recent UAS with the prior UAS identifies functional decline for most ADLs.

The patient needs a caregiver available beyond 8 hours per day to improve management of her toileting/incontinence care needs.

The information provided for review provides a somewhat fragmented picture of the patient's prior and current functional status. The prior UAS already indicated functional impairment for most daily activities. The current UAS indicates further physical functional decline and some degree of cognitive decline compared to the prior UAS. The insurer's case summary supports the patient's need for assistance with ambulation from the physical therapy (PT) note, but the rest of the PT information provided in the case summary did not provide a clear understanding of the patient's ADL status at that time. There are no recent medical records or PT notes available for review; but the letters from the physician and appealer indicate the patient has continued to need help with all ADLs. The current status of the patient's mobility is not clearly described, but it appears she can transfer and walk only if a caregiver is available to assist. 

Based on available information, it is medically necessary for the patient to have assistance with all daily activities. This includes preparation and service for all 3 meals per day and assistance with eating. She needs assistance with routine morning and evening ADLs (bathing, personal hygiene, dressing), and for toileting/incontinence care, transfers and walking which occur at various unscheduled times of the day and night. 

With PCA 84 hours per week, 12 hours per day, the patient will benefit from additional ADL assistance during the evening that is not available to her with her current 8 hours of service, including extended time to ensure adequate food and fluid intake, additional toileting and incontinence care later into the evening, extended period of time for assistance with pain management (e.g., repositioning, assist with medication). 

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 personal care aide (PCA) hours 7 days a week 12 hours a day, 84 hours a week is overturned. Medical Necessity is substantiated.