Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dislocation of left shoulder, osteoarthritis, osteoporosis  

Treatment: increase in personal care assistance hours from 37 hours to 84 hours per week

The insurer denied coverage for increase in personal care assistance hours from 37 hours to 84 hours per week. The denial is reversed.

This patient is a female with diagnoses that included hypertension, dislocation of left shoulder, osteoarthritis, osteoporosis, mixed incontinence, muscle weakness, insomnia, depression, h/o falling, difficulty walking, age related physical debility. 

The patient female lives alone in apartment in elevator building. The patient fell. UAS reports patient has left shoulder dislocation; a relative reports left shoulder fracture, rotator cuff damage (no orthopedic or other records are available). Patient lives alone and has been receiving personal care assistance (PCA) services. A family member who was present at the assessment and was providing additional care following the fall/injury lives out of state and planned to return home (other daughter also lives out of state).The patient has no other informal caregivers identified in the UAS. The UAS indicates a significant functional decline following fall and injury. The patient's family member wrote in the appeal application that she is requesting increase of PCA services to 12 hours per day and sleep-in at night. The insurer's final denial letter indicates request only for PCA 84 hours per week (12 hours per day), which was denied; but PCA hours were increased from 37 to 47 hours per week. An external appeal was requested.

The current UAS indicates the patient needs maximal or extensive (weight-bearing) assistance for most daily activities (some IADLs are total dependence). In addition to the recent injury, the patient has some medical conditions that most likely contribute to her functional impairment. She has arthritis which may contribute to decreased mobility. She has h/o depression, and as per daughter, the patient has significant anxiety disorder. Mood disorders are common in the elderly and can have a significant adverse effect on daily function and contribute to various health problems. The patient has nonspecific weakness which is not clearly attributed to a specific problem. The patient has poor appetite and is underweight. Mood disorders can cause decreased appetite and weight loss, which can result in weakness and decreased functional capacity. It is not known whether there are any other medical conditions causing these problems.

In frail elderly people, an acute medical episode (e.g. trauma, medical illness), even if it is not a critical event, can cause significant decline in the patient's health and functional status. For a patient with pre-existing weakness, and difficulty with mobility and performing daily tasks, an injury causing very limited use of one arm can cause a major change in ability to function independently. Decreased ability to use one arm can cause further destabilization of walking and transfers. At this age, with pre-existing disability and with some degree of cognitive impairment, learning compensatory ways to complete daily activities can be difficult. When certain skills are lost for a period of time, it may be difficult for the patient to resume activity at her previous level even after the shoulder injury improves.

The patient has no informal caregivers to provide assistance when the PCA is not present. In the absence of informal caregivers who can provide assistance with daily activities when needed, then PCA services are indicated to provide the necessary assistance with ADLs.

There is a concern that the patient needs assistance at night. The daughter noted in the appeal letter that she wanted an aide at night, but the request in this appeal (as per the insurer's final denial letter) was for PCA services 84 hours per week (12 hours per day x 7 days per week). It is not known is there is separate request for night services. The number of hours that can be recommended from this review is limited by the amount requested, as per the insurer's final adverse determination notice; i.e. 84 hours per week (12 hours per day, 7 days per week).

Personal Care Assistance 84 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment.

Based on the above, the medical necessity for the requested increase in personal care assistance hours from 37 hours to 84 hours per week is substantiated.  The insurer's denial is reversed.