Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid arthritis, lumbar stenosis, status post intrathecal pain pump placement, cardiac arrest, bilateral rib fracture.

Treatment: Personal Care Aide (PCA) Level 2 Services of 9 hours per day, 7 days per week for a total of 63 hours per week.

The insurer denied coverage for PCA Level 2 Services of 9 hours per day, 7 days per week for a total of 63 hours per week.

The denial is overturned.

This is a female patient with a past medical history of hypertension, chronic embolism, thrombosis of bilateral femoral veins, aortic stenosis, hypothyroidism, anemia, bilateral rib fracture, rheumatoid arthritis, lumbar stenosis, unsteady gait, limited range of motion (ROM) and chronic pain. The patient was admitted to the hospital to have a pain pump inserted and she had a cardiac arrest after the procedure. Cardiopulmonary resuscitation (CPR) was performed, resulting in rib fractures, which caused significant pain and difficulty breathing. She remained in the hospital for 19 days.   

Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient lives alone in a one-bedroom basement apartment. There are 12 steps to get to her apartment. Her children are supportive in her care.  The UAS (Uniform Assessment System) indicated the patient has daily, severe pain and decreased range of motion (ROM) in her shoulders; the patient has difficulty with daily activities requiring upper extremity function (e.g., bathing, personal hygiene, toileting, upper body dressing). Pain and decreased ROM also affect her lower extremities which limits walking, transfers, lower body dressing. 

MLTC (managed long-term care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. When the patient needs assistance with toileting, incontinence care, transfer, walking, food/fluids, this is not stand-alone safety supervision. This is assistance the patient needs for proper and safe completion of daily activities. These care needs must be considered in the determination of the patient's personal care service hours.

Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have a caregiver present for a more extended period of time each day. The patient needs assistance for instrumental activities of daily living (IADLs) and (activities of daily living (ADLs) that occur at various scheduled and unscheduled times throughout the day. This includes routine household tasks, and preparation/service of all 3 meals; routine morning and evening ADLs (e.g., bathing, dressing, personal hygiene); and unscheduled/recurring activities, including toileting related tasks/incontinence care; mobility around the home (transfers, walking). Without adequate assistance, the patient is at risk for adverse health and safety events, e.g., falls/injury; skin damage due to inadequate toileting/incontinence care; nutritional decline, dehydration; inadequate pain management.

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 Aide (PCA) Level 2 Services of 9 hours per day, 7 days per week for a total of 63 hours per week is overturned. Medical necessity is substantiated.