Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Femur fracture, coronary artery disease with congestive heart failure (CHF), generalized osteoarthritis, hypertension, stage 3 chronic kidney disease, atrial fibrillation, stage 4 pressure ulcer, and iron deficiency anemia 
Treatment: personal care aide (PCA) 7 days x 24 hours split shifts 
The insurer denied coverage for personal care aide (PCA) 7 days x 24 hours split shifts 
The denial is overturned
This is an elderly adult with chronic medical problems including a history of coronary artery disease with congestive heart failure (CHF), generalized osteoarthritis, hypertension, stage 3 chronic kidney disease, atrial fibrillation, stage 4 pressure ulcer, and iron deficiency anemia. The patient is status post coronary artery bypass grafting, myocardial infarction and a permanent pacemaker placement. The patient sustained a Right Femur fracture requiring surgical repair and needed extensive rehabilitation.
The New York State (NYS) Comprehensive Assessment form was reviewed. The patient's cognitive skills are described as moderately independent. The patient's memory is intact with some forgetfulness. The patient is assessed as requiring assistance for most Instrumental Activities of Daily Living (IADL) and activities of daily living (ADL) tasks. The patient needs maximal assistance with meals, shopping and bathing. Extensive assistance is also needed with dressing, toilet use, toilet transfer, walking and weight bearing. The patient is totally dependent for shopping. The patient uses a wheelchair as their primary method of locomotion but needs extensive assistance and can only manage 15 feet of wheeling. The patient is frequently incontinent of urine. The patient is treated with Xarelto for atrial fibrillation. The patient's residence requires 10 steps to reach the indoor chair lift. The patient resides with their wife.
Personal care aide (PCA) hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance.
Based on the enclosed documents reviewed, the patient's health and safety cannot be appropriately provided and maintained with 52 PCA hours/week. The patient is at risk for falls, had recent right femur surgery, is incontinent of urine and has a stage 4 pressure ulcer. The patient is medicated with Xarelto which increases the risk of serious injury from falls. The patient needs frequent diaper changes and their physician notes that repositioning and diaper changes are required every 2 hours day and night. The patient also needs extensive assistance with weight bearing, toilet use and toilet transfers and is essentially bound to their wheelchair.
From a family medicine and home care perspective, as well as within a reasonable degree of medical judgment, the carrier's denial of increased hours of PCA per week is not medically appropriate. The carrier's decision to deny the patient's increased PCA hours should be reversed and 7 days X 24 hours split shift approved.
Based on the above, the insurer's denial must be reversed. 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) 7 days x 24 hours split shifts services is substantiated.