Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Arthritis.
Treatment:  Personal Care Assistance (PCA) services, level 2: 6 hours per day, 1 day per week; 9 hours per day, 3 days per week; 5 hours per day; 1 day per week; 4 hours per day, 1 day per week (total 42 hours per week).
 
The insurer denied the Personal Care Assistance (PCA) services, level 2: 6 hours per day, 1 day per week; 9 hours per day, 3 days per week; 5 hours per day; 1 day per week; 4 hours per day, 1 day per week (total 42 hours per week).  The denial was overturned.

This is a female patient who lives alone and has been receiving personal care services (PCS) 5 days per week; she attended adult day care several days per week, and has informal support from family.  The patient does not currently have day care services since adult day care closed in recent months due to COVID-19.  She is requesting additional PCS hours, mostly for assistance for the weekends.  She has a history of hypertension, hyperlipidemia, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, gastroesophageal reflux disease (GERD), osteoarthritis, history of falling, glaucoma, low vision right eye, malignant neoplasm of nasopharynx, urinary incontinence, hearing loss bilateral, insomnia, constipation. 

Arthritis is a common cause of functional impairment and disability in older people.  Symptoms can fluctuate in frequency and severity.  Mobility-related daily activities are often restricted due to pain, stiffness and decreased range of motion of affected joints.  The UAS reports patient has pain in lower back, and multiple joints in upper and lower extremities.  The UAS indicates pain is mild, does not occur daily, and relieved with treatment.  However, the UAS functional assessment for IADLs and ADLs suggests the patient's symptoms may be more frequent and of greater intensity.  The patient needs either maximal assistance or is totally dependent for housekeeping tasks, outdoor activities (shopping, transportation) and stairs.  It does not appear that the patient has significant cognitive impairment, and so the cause of her difficulty with these IADLs is mostly due to impaired physical ability.  These tasks require standing, walking, bending, reaching, and so the patient's ability to perform these tasks is limited by back and joint pain.  For ADLs, the patient needs extensive assistance with bathing and lower body dressing, which requires bending of back and lower extremities.  She needs extensive assistance with toilet use, which involves ROM of upper extremities. 

The patient has multiple medical conditions, and she has been able to maintain some degree of independence in her home.  Providing additional hours of assistance with daily activities will help her avoid falls and accidents during hours of the day when she is most active, and relieve some of the stress of managing her daily routine that has become increasingly difficult due to her health problems.  It is not known whether she has help from informal caregivers at this time; but considering she is asking for PCS 42 hours per week, it is reasonable to conclude that she does not have informal support for the hours she is requesting.  Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services. 

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

The carrier's denial of coverage for Personal Care Assistance (PCA) services, level 2: 6 hours per day, 1 day per week; 9 hours per day, 3 days per week; 5 hours per day; 1 day per week; 4 hours per day, 1 day per week (total 42 hours per week) is overturned.  The medical necessity is substantiated.