Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Asthma. 
Treatment: Personal Care Aide (PCA) Level 2 services: 8 hours per day, 5 days per week for a total of 40 hours per week. 

The insurer denied coverage for PCA Level 2 services: 8 hours per day, 5 days per week for a total of 40 hours per week. 

The denial is overturned. 

This is a female with a past medical history of osteoarthritis, hypertension, hyperlipidemia, gastroesophageal reflux disease, coronary artery disease and asthma. The patient lives at home with her son. She has been receiving personal care aide (PCA) services 25 hours per week (5 hours x 5 days). The patient's son and another child (or child in-law) provides informal help. The patient's husband died recently. It was noted that he provided the patient with some assistance for activities of daily living (ADLs). The patient requested an increase of PCA services to 40 hours per week (8 hours x 5 days). 

The patient's functional status as noted in the Uniform Assessment System (UAS) report indicates the patient is totally dependent or needs maximal assistance with housework, meal preparation, shopping; extensive assistance with transportation, stairs, finances; limited assistance with medications, and phone use. For ADLs, patient needs maximal assistance for bathing, lower body dressing; extensive assistance for walking, toilet transfer; limited assistance for all other ADLs. A significant change from previous UAS is noted; the patient needed limited assistance for walking before, and now requires extensive (weight-bearing) assistance. 

The information provided for review, i.e. the patient's medical history, functional status and symptoms as noted in the UAS reports; the physician's confirmation of the severity of the patient's symptoms due to osteoarthritis; history of COVID-19 pneumonia; and the loss of the patient's husband and caregiver, presents a reasonable perspective of the patient's medical, functional and social situation, and provides a clinical basis for her need for assistance with all ADLs and instrumental activities of daily living (IADLs). The patient has chronic symptoms including pain, decreased range of motion, dyspnea, and fatigue. Her symptom burden most likely increased this year following COVID-19 pneumonia and she still may have persistent effects. Her life has changed permanently due to the death of her husband. She is most likely still coping with the painful emotional effects of loss; and possibly with depressive features which may also affect her functional ability. She also has to adjust to the loss of her husband as caregiver. It is necessary to implement a care plan that ensures the patient's basic daily care needs are met throughout the day in order to reduce the risk of adverse health and safety events. The patient needs assistance for all daily activities. It is medically necessary and in the patient's best interest to have a caregiver present to provide assistance for all daily activities. Providing the patient with adequate assistance for mobility related activities can help relieve the physical burden associated with daily activities. 

Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. Considering the request for PCA services is for 8 hours per day, 5 days per week, it is reasonable to conclude that there are no informal caregivers who are able to provide care during these hours on a regular basis. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities. 

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

The carrier's denial of coverage for the requested PCA Level 2 services: 8 hours per day, 5 days per week for a total of 40 hours per week is overturned. The medical necessity is substantiated.