Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease; Cognitive decline.

Treatment: Personal Care Aide (PCA) Services for a total of 40 hours per week.

The insurer denied coverage for Personal Care Aide (PCA) Services for a total of 40 hours per week.

The denial is overturned. 

This female patient has anxiety, depression, coronary heart disease with unstable angina, hypertension, dizziness, cardiac pacemaker, hypercholesterolemia, glaucoma, osteoarthritis, unsteadiness, and constipation contributing to progressive functional impairment. She lives alone. The most recent Uniform Assessment System (UAS) functional status report indicated she needs maximal assistance for household related tasks. For activities of daily living (ADLs), the patient needs extensive assistance for bathing and dressing; and limited assistance for most other ADLs.

The physician's office notes identify short term memory impairment and other signs of cognitive decline. The patient had moderate depression. The patient also has symptoms of anxiety, which often occurs with depression. Depression in the elderly is associated with functional decline. The patient's recent signs of cognitive impairment may be related to her depression.  

The patient has chronic medical conditions that affect her ability to perform ADLs. When older people with physical impairments live alone, they often have no choice but to attempt daily tasks even if they do not feel secure about their ability to perform the activity. In this case, the patient has chronic joint pain and stiffness, back pain, and dizziness resulting in unsteady gait. The UAS noted that when the aide is present, she assists with toilet transfer. Providing limited/contact guard assistance is a useful intervention, as it stabilizes a person during mobility and can help prevent a fall. When elderly people fall, there is increased risk of serious injury associated with substantial morbidity and increased risk of death. 

The physician expressed concern about the patient's nutritional status. Elderly people who live alone are at risk for malnutrition. With the current PCA hours, there are too many meals per week when the patient is alone, and her intake is unknown. With her declining memory, it is unlikely an accurate history of her food intake can be obtained without a caregiver present. The physician reported the presence of a small stage 2 sacral pressure ulcer that has been there for months. It raises the question that perhaps wound healing may be slow due to impaired nutrition.

Considering the patient's medical conditions, recent history of cognitive impairment and depression, and the chronic nature of her physical symptoms, it is medically necessary for the patient to have assistance with daily activities 7 days per week and more hours per day. 

It is suggested that the patient has services 7 days per week, and possibly consider splitting hours to provide some assistance later in the day so the aide is present for all meals, and possibly evening ADLs. The patient's health conditions place her at risk for adverse outcomes including falls, injuries, malnutrition, impaired wound healing.  When the son-in-law's mother leaves the patient's home, there are no other informal caregivers who can provide additional assistance. The patient's daughter has health problems that limit her ability to provide assistance. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  When informal caregivers are unable to provide necessary care on a consistent basis when needed, then personal care services are indicated to provide assistance with all daily activities during hours when care is needed and not provided by informal caregivers.

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 Personal Care Aide (PCA) Services for a total of 40 hours per week is reversed.  The medical necessity is substantiated.