Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, hypertension, obesity, prediabetes, osteoarthritis, bilateral hearing loss, stress incontinence.
Treatment: personal care assistance (PCA) services for 5 days per week, 9 hours per day, 45 hours per week.

The insurer denied coverage for personal care assistance (PCA) services for 5 days per week, 9 hours per day, 45 hours per week.  The denial is overturned. 

This patient has significant functional impairment associated with various medical conditions and needs assistance with most daily activities. She lives alone and was receiving personal care assistance (PCA) services 5 days per week, 7 hours per day. The patient also has informal help from her daughter; but the daughter reports that due to her work schedule, she is unavailable to assist her mother until after 5 p.m., and the aide's shift ends at 3 p.m. The daughter provides assistance in the evening and weekends. She requested (as patient designee) increase of PCA services to 9 hours per day, 5 days per week, which was denied. The insurer reported that based on clinical evaluation, the patient does not require PCA 9 hours per day; but approved PCA 7 hours per day, 7 days per week, total of 49 hours per week. Notes from the social worker indicate the daughter declined the new hours because the patient has informal help on weekends; but additional hours are needed during weekdays. An external appeal was requested.

Patient's cognitive status as described in the Uniform Assessment System (UAS) includes: decision-making for daily tasks was reported as modified independence (some difficulty in new situations). She was oriented person, place, and time. No specific type of memory impairment was identified, except needing reminders for medications. She could verbalize emergency plan to call 911. The patient's need for assistance with daily activities appears to be primarily due to physical impairment from chronic medical conditions. 

The patient has chronic pain and the social worker's summary of the UAS indicates pain has increased since last assessment. The UAS includes diagnosis of osteoarthritis with joint pain, but specific joints are not noted. However, the UAS indicates patient has back and lower extremity pain, which may be due to arthritis of spine and lower extremity joints. Upper extremity range of motion is limited (she can only raise arms to shoulder level). It was noted patient has difficulty opening medication bottle, which suggests decreased hand function, possibly due to arthritis. The UAS also reported patient has pain in her feet which limits her ability to walk; no specific diagnosis was identified.

Considering the information provided for review, it is medically necessary and, in the patient's, best interest to have assistance for Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs) throughout the day, including ADLs that occur at unplanned and recurring times throughout the day, i.e., mobility and toileting. The UAS describes the patient's need for extensive help with mobility and toileting, which is needed throughout the day at various unscheduled times. The current PCA schedule is 7 hours per day 8 a.m. -3 p.m. (as reported by the daughter). Moving these hours to a later time (e.g., 10 a.m. -5 p.m.) leaves the patient with delayed help in the morning for breakfast and morning ADLs. It is likely the patient needs prompt attention to toileting and incontinence care early in the morning, as she has no help for these tasks during the 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 personal care assistance (PCA) services for 5 days per week, 9 hours per day, 45 hours per week is overturned. Medical necessity is substantiated.