Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease, Hypertension, Congestive Heart Failure, and Parkinson's Disease
Treatment: Personal Aide Care (PCA) Level 2: 12 hours per day- 5 days per week and Consumer Directed Personal Aide Care (CDPAP) 12 hours per day- 2 days per week for a combined total of 84 hours per week
The insurer denied coverage for Personal Aide Care (PCA) Level 2: 12 hours per day- 5 days per week and Consumer Directed Personal Aide Care (CDPAP) 12 hours per day- 2 days per week for a combined total of 84 hours per week.
The denial is overturned.

This case involves a female diagnosed with coronary artery disease, hypertension, congestive heart failure, hypothyroidism, anemia, osteoarthritis, and Parkinson's disease who was being assessed for an increase in personal aide care hours. The assessment noted that the patient was alert and oriented to person and place. She lived alone in a studio apartment on the eighth floor of an elevator accessible building for senior citizens. She had memory problems, difficulty with word finding, reported feeling sad, anxious, crying, and depressed related to her current health conditions and pain. Her medical conditions limited her range of motion, with noted muscle weakness, muscle pain, and unsteady gait, fatigue, and pain and stiffness in the joints. There was a decline in some activities of daily living and independent activities of daily living due to worsening symptoms of Parkinson's disease. The patient reported urinary incontinence daily with the need for liners, pull-ups, and under pads. She had no falls in the last 90 days and was able to perform some meal preparations. She was receiving Physical Therapy and Occupational Therapy 2 times a week at home. Per the patient's daughter, the patient had worsening symptoms of osteoarthritis and Parkinson's causing constant pain, increased fatigue, with a decline in cognition and mood swings. She was completely dependent on caregivers for assistance and required frequent diaper changes to prevent bedsores and infections. The patient's daughter stated that the patient has sustained multiple falls while trying to get up on her own at night and the treating physician recommended assistance 12 hours/day, 7 days/week. This review pertains to the increase in personal aide care.

Literature notes that personal assistant services allow patients to remain in their home to receive care rather than receiving treatment and assistance within the context of a skilled nursing facility or other assisted living facilities. The information provided for the review noted that the patient lives alone and had multiple diagnoses, that limited her ability to complete activities of daily living and independent activities of daily living.

Based upon the provided information, the current request is supported. As such, the coverage for Personal Aide Care (PCA) Level 2: 12 hours per day- 5 days per week and Consumer Directed Personal Aide Care (CDPAP) 12 hours per day- 2 days per week for a combined total of 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's denial of coverage for Personal Aide Care (PCA) Level 2: 12 hours per day- 5 days per week; Consumer Directed Personal Aide Care (CDPAP) 12 hours per day- 2 days per week for a combined total of 84 hours per week is overturned. Medical Necessity is substantiated.