Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, osteoporosis

Treatment: Personal care aid (PCA) services 7 days a week, 12 hours a day

The insurer denied coverage for PCA services 7 days a week, 12 hours a day

The denial is reversed.

This male patient has a past medical history of skin cancer, osteoporosis, vision problems, hypertension, gastroesophageal reflux disease, hyperlipidemia, insomnia and osteoarthritis. The patient was approved for personal care aid (PCA) services 7 days per week, 8 hours per day. The patient requested PCA services 7 days per week, 12 hours per day, which was denied. 

The patient lives alone. His history includes age related cognitive decline, physical debility, severe stamina loss, limited range of motion (ROM), postural instability, malignant neoplasm of skin status post radiation therapy, hypertension, congestive heart failure (CHF) III, hyperlipidemia, migraine headaches, vertigo with daily dizziness, history of (h/o) falls, ataxic gait, shortness of breath, osteoarthritis of shoulder and knees, chronic severe pain with joint deformity, lumbar degenerative disc disease, lower back pain, muscle weakness, insomnia, blind left eye due to trauma, impaired vision right eye, cataract, hearing loss. The patient is unable to walk independently without human assistance and walker. He is dependent on a home health aide (HHA) to carry out normal activities of daily living (ADLs) and household tasks, meal preparation, and reminders for medication. He needs assistance with mobility to prevent falls. Recommendation is for home care 12 hours per day, 7 days per week.

This patient has multiple medical conditions, functional impairment, and needs assistance for most daily activities. The most recent Uniform Assessment System functional status report indicated the patient needs maximal assistance or is totally dependent for household related tasks; and extensive assistance for other instrumental activities of daily living (IADLs). The patient needs extensive assistance for most ADLs.

It is clear that he needs to use the toilet during the other 16 hours of the day. Until he goes to bed for the night, he most likely needs to use the toilet at least one or two times after the aide leaves. Each time he needs toileting when assistance is not available is a safety risk for falls.

With 8 hours of PCA services per day, it appears unlikely that all evening ADLs can be completed before the aide leaves each day. Considering the patient's functional status and symptoms noted, it is apparent that the patient needs considerable assistance for most IADLs and ADLs. Therefore, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day to provide assistance for daily activities. 

The only informal caregiver identified in the available records is a friend. Assistance from informal caregivers is voluntary as per New York state (NYS) regulations for personal care services. When informal caregivers are not available to provide necessary support for daily activities, then PCA services are indicated to provide assistance for all IADLs and ADLs when needed throughout the day. 

The patient has substantial functional impairment and needs assistance for all daily activities around his home and outdoors during the hours of the day from morning until he goes to bed at night. There are some concerns for the patient's safety if he needs to get out of bed at night. The patient did not request nighttime services, and so he may be able to manage nighttime activities at the present time. PCA services 7 days per week, 12 hours per day are medically necessary. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for the requested increase in PCA services 7 days a week, 12 hours a day is substantiated. The insurer's denial is reversed.