Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Home care services. 
Treatment: Personal care assistant (PCA) services of 7 days per week, 12 hours per day for a total of 84 hours per week. 

The insurer denied coverage for personal care assistant (PCA) services of 7 days per week, 12 hours per day for a total of 84 hours per week. 

The denial is overturned. 

The patient is a female with past medical history of hypertension, coronary artery disease, congestive heart failure with peripheral edema, cerebrovascular disease, hyperlipidemia, persistent shortness of breath, chronic debilitating pain, degenerative disc disease, sarcopenia, osteoporosis, gastroesophageal reflux disease, glaucoma, insomnia, fatigue and urinary incontinence resulting in functional impairment and decline in ability to perform daily activities. The patient was living alone at the time of the Uniform Assessment System (UAS). The patient was receiving personal care assistant (PCA) services 6 hours per day, 7 days per week. The most recent UAS provided for review was done (telephonic). The functional status report for Instrumental Activities of Daily Living (IADLs) indicates patient needs maximal assistance or is totally dependent for meal preparation, housework, shopping and stairs; extensive assistance with finances and transportation; and supervision for medications and phone use. For Activities of Daily Living (ADLs), she needs extensive assistance for bathing, lower body dressing, walking, transfer toilet; limited assistance for upper body dressing, toilet use, bed mobility. She needs setup help with personal hygiene and eating. 

The patient needs medication reminders and assistance with finances. The patient has multiple physical problems contributing to gait instability. As noted, she has chronic knee and hip pain from arthritis; pain in her feet (neuropathy); pain with ambulation from Peripheral vascular disease (PVD) claudication. Lower back pain and kyphosis can also cause difficulty walking. The UAS nurse assessor observed the patient (by video access during assessment) walking with slow unsteady gait; and had difficulty lifting her foot; PCA provided underarm support with walking and transfers. Sources of pain can cause substantial physical functional impairment. Lower extremity symptoms (pain, decreased range of motion (ROM)) and lower back pain and stiffness affect all aspects of mobility, including walking, stairs, and transfers (UAS reports patient has difficulty moving to standing position unassisted; needs PCA support for transfer from toilet, recliner and bed). 

The request for increase of services is for PCA 12 hours per day, 7 days per week. The patient has substantial functional impairment and needs assistance for most daily activities around her home from morning until she goes to bed at night. Personal Care Assistant services 7 days per week, 12 hours per day; 84 hours per week is medically necessary. 

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

The insurer denial for requested Personal Care Assistant (PCA) services of 7 days per week, 12 hours per day for a total of 84 hours per week is substantiated.  The insurer's denial is overturned.