Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, hyperlipidemia, gastroesophageal reflux disease, prediabetes mellitus, and spinal stenosis.

Treatment: Personal care aide (PCA) Level 2 services, 12 hours per day, 7 days per week, totaling 84 hours per week.

The insurer denied coverage for PCA Level 2 services, 12 hours per day, 7 days per week, totaling 84 hours per week.

The denial is overturned.

This female has functional impairment associated with various medical conditions and needs significant assistance for most daily activities. She lives alone. She has been receiving assistance through PCA (personal care assistant) services 8 hours per day, 5 days per week (Monday-Friday 8am-4pm), total of 40 hours per week. As per the Uniform Assessment System (UAS), patient was also receiving informal support from family; but as per the daughter's appeal letter, informal caregivers are unable to provide the assistance the patient needs on weekends; and the patient needs additional hours on weekdays also. Request was made to increase PCA services to 84 hours per week, which was denied. External appeal was requested. 

The patient depends on caregivers for most instrumental activities of daily living (IADLs), which is mostly due to her physical limitations to perform these tasks (e.g., housework, preparing meals, shopping); but it is likely that cognitive impairment is a factor with tasks such as managing finances and medications.  It appears the patient's physical impairments are also the primary cause of her need for assistance with activities of daily living (ADLs); however, memory loss and impaired ability to make safe decisions can contribute to problems with ADL function and can increase risk of falls and household accidents.  

The patient lives alone and the daughter reported that she is unable to provide the assistance the patient needs during non-PCA hours. The patient requires substantial assistance for all toileting care, including incontinence. Inadequate cleaning after toileting and prolonged exposure to wet soiled diapers, increases risk of skin damage (e.g., dermatitis, fungal infection); may increase risk of urinary tract infection; and is a source of discomfort for the patient. PCA services 8 hours per day, 5 days per week (current services) is inadequate. The patient needs assistance daily, at least from morning to evening for timely and effective cleaning/hygiene after toileting/incontinence.

Considering the patient's medical history and functional status as noted in the available records, it is apparent that the patient needs substantial assistance for most ADLs and IADLs. Therefore, it is medically necessary, and in the patient's best interest, to have a caregiver present throughout the day to assist with daily activities. The patient needs assistance for IADLs and ADLs that occur at various scheduled and unscheduled times throughout the day. This includes preparation/service of all 3 meals, routine household tasks, medications, routine morning and evening ADLs (bathing, dressing, personal hygiene), unscheduled/recurring activities including toileting/incontinence care and out-of-bed mobility (transfers, walking). Without adequate assistance, the patient is at risk for adverse health and safety events, e.g., skin damage due to incontinence/inadequate cleaning after toileting; nutritional decline; dehydration; falls/injury; medication errors (e.g., missed doses, taking incorrect pills).

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, 12 hours per day, 7 days per week, totaling 84 hours per week is overturned. Medical Necessity is substantiated.