Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heart failure, chronic venous insufficiency. 
Treatment: Personal Care Aide (PCA) Level 2: 6 hours per day - 5 days per week - for a total of 30 hours per week. 
The insurer denied coverage for Personal Care Aide (PCA) Level 2: 6 hours per day - 5 days per week - for a total of 30 hours per week. 
The denial is overturned. 

This is an elderly female with functional decline associated with several medical conditions and needs help with most daily activities. The patient lives with her husband, who is identified in the Uniform Assessment (UAS) as the only informal helper. The patient receives personal care aide (PCA) services to assist with Activities of Daily Living (ADLs) and Incidental Activities of Daily Living (IADLs); currently 20 hours per week (4 hours per day, 5 days per week). The patient (via designee) requested PCA services 30 hours per week (6 hours per day, 5 days per week), which was denied. 

The most recent Uniform Assessment (UAS) provided for review for IADLs indicates patient was totally dependent for ordinary housework; she needed maximal assistance for meal preparation, shopping, managing finances and medications; extensive assistance for stairs, transportation; independent for phone use. For ADLs, she needed extensive assistance for bathing, dressing lower body, transfer toilet, toilet use, walking, locomotion; limited assistance for dressing upper body, bed mobility; setup help: personal hygiene, eating. 

The patient was hospitalized twice this year due to heart failure; then due to flu. The patient's ability for decision making for daily tasks was described as modified independence, some difficulty in new situations. She was oriented to person, place and time, with short term memory problems. 

The records indicate the patient has heart failure. The physician also reported diagnosis of chronic venous insufficiency, so either condition may contribute to the patient's edema. Fatigue and weakness are common symptoms associated with heart failure. The UAS reports the patient has fatigue to the extent that she is unable to finish daily activities. Nursing comments included several references to weakness limiting various daily activities. The UAS reports the patient has episodes of dizziness. The combined effects of pain, fatigue, weakness, dizziness can be debilitating and lead to low activity tolerance. 

The patient needs extensive assistance with toilet transfer and toilet use. This is consistent with report of patient's knee, hip and low back pain which can cause difficulty with transfers. For toilet use, the caregiver helps with cleaning and clothing adjustment. The patient needs extensive help with toilet use and lower body dressing. In order to facilitate safe effective completion of toileting related tasks, and help prevent adverse health and safety events, the patient needs assistance with toileting/incontinence care throughout the day. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care aide (PCA) Level 2: 6 hours per day - 5 days per week - for a total of 30 hours per week services is substantiated.