Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe dementia, gastroesophageal reflux disease, chronic kidney disease, hyperlipidemia, hypertension, arthritis, arteriosclerotic heart disease, scoliosis, right bundle branch block, Bell's palsy and gallstone pancreatitis

Treatment: Personal Care Assistance (PCA) services of 124 hours per week

The insurer denied coverage for personal care assistance (PCA) services of 124 hours per week

The denial is overturned

The patient is a female with a past medical history of severe dementia, gastroesophageal reflux disease, chronic kidney disease, hyperlipidemia, hypertension, arthritis, arteriosclerotic heart disease, scoliosis, right bundle branch block, Bell's palsy and gallstone pancreatitis.  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her daughter were present on the call.  The patient lives alone on the 2nd floor of a senior building with elevator access.  The patient's daughter reported that the patient has a history of wandering, including an episode that occurred two weeks ago.  The patient's daughter also reported the patient had 2 or more falls in the last three months, and she sustained multiple bruises and abrasions.  There was no major injury.  
Needs are: 

-	Total dependence for meals, housework, finances, medications and shopping;
-	Maximal assistance for stairs, transportation, bathing and Instrumental Activities of Daily Living (IADLs);
-	Extensive Assistance for phones, personal hygiene, dressing, walking, locomotion, toilet transfers and use (worsened between two UAS performed). 
-	Limited assistance for bed mobility and eating.
-	Cognition:  There is severe impairment (increased between UAS 
-	Continence: There is urinary and bowel incontinence (UAS notes need for frequent changes). 

An increase to personal care assistance (PCA) services of 124 hours per week is being requested.

The patient's daughter explained that the patient has multiple health issues, which includes falls, wandering and incontinence.  The patient's daughter also stated that, after the re-evaluation, the nurse recommended 14 additional hours per week.  However, the patient's daughter explained that this was not of use as the patient's issues occur when she is unattended at night.  The daughter lives 2 12 hours away but has a friend to cover 30 hours of care to supplement the home health aide's hours. The patient's daughter disagreed with the insurer's determination that additional hours are not medically necessary.  The patient's daughter requested the additional hours be granted so that the patient may live the rest of her life at home, where she is comfortable, safe from COVID-19 (2019 Novel Coronavirus) and other complications that can arise in a facility.
The patient has severe dementia and extensive needs with activities of daily living (ADLs).  Physician notes and the Uniform assessment indicate that her dementia is severe and worsening.  Functional capacity has also decreased.  She is incontinent of bowel and bladder.  She now needs at least extensive assistance with locomotion, walking and toilet transfers and use.  She is at risk for pressure sores.

The provision of diapers is not by itself adequate for prevention of pressure sores.  As noted in "Preventing pressure ulcers."  In https://www.ncbi.nlm.nih.gov/books6430/ updated in the last few years changing diapers regularly (need for this is noted in UAS) and positioning are also necessary.  She follows commands poorly. The family friend who acts as caregiver cannot provide the hours necessary to provide for these services at night. 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 the requested Personal Care Assistance (PCA) Services of 124 hours per week is reversed.  Medical Necessity is substantiated.