Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Osteoporosis

Treatment: Increased personal care aide (PCA) services to: 8 hours per day, 7 days per week; total of 56 hours per week

The insurer denied coverage for increased PCA services to: 8 hours per day, 7 days per week; total of 56 hours per week.

The denial is overturned.

This is a female patient, with an extensive medical history, who lives alone and needs assistance with various daily activities. She was approved for personal care aide (PCA) services: 4 hours per day, 28 hours per week. She has very limited informal caregiver support and requested an increase of PCA services to 8 hours per day, 56 hours per week, which was denied.

Physician records and the Uniform Assessment System (UAS) both indicate that the patient has substantial physical limitations due to symptoms from chronic conditions.  Her medical history includes: osteoarthritis, osteoporosis, major depressive disorder, generalized anxiety disorder, chronic bronchitis, bronchospasm, hypertension, diabetes mellitus (DM), and coronary artery disease (CAD). She needs extensive to maximal assistance for housekeeping tasks, shopping, and medications. For activities of daily living (ADLs), bathing and lower body dressing, she needs limited assistance; other ADLs were noted as supervision or independent setup help. 

The patient has arthritis affecting multiple joints of her upper and lower extremities. Arthritis is a frequent cause of chronic pain and functional impairment.  For people with chronic pain, performing daily activities can be stressful, and is associated with depression and anxiety, which are both noted in the UAS and physician's records (medication list includes use of antidepressants). She also has dyspnea. Dyspnea can be a debilitating symptom and the effect on daily activities can be significant.  When dyspnea and chronic pain co-exist, the burden of physical activity during daily tasks can be substantial. The patient has severe obesity. Obesity is associated with decreased function for daily activities, and is probably a contributing factor in the patient's functional decline. 

Providing assistance for more hours of the day can help relieve some of the patient's physical burden of mobility and provide assistance with various household and personal care tasks. Based on observations by physicians regarding the patient's functional decline, it appears that she needs additional help with daily activities. She lives alone and appears to have very limited support from informal caregivers. Considering her medical history, associated symptoms, and the adverse effects on her ability to perform physical activities, it is medically necessary and in the patient's best interest to provide assistance with daily activities for a more extended period of the day when the patient is most active. This can relieve some of the physical stress of daily activities, help prevent falls and household accidents that can occur as a result of the patient's impaired mobility, and possibly relieve some of the anxiety associated with the stress of daily functioning.

PCA services: 8 hours per day, 7 days per week; total of 56 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 carrier's denial of coverage of PCA services: 8 hours per day - 7 days per week - for a total of 56 hours per week, is overturned. The medical necessity is substantiated.