Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, severe degenerative disease of spine and knees, urinary incontinence, major depression, osteoporosis, and dizziness

Treatment: Personal care assistant (PCA) services 12 hours per day, 7 days per week

The insurer denied coverage for personal care assistant (PCA) services 12 hours per day, 7 days per week

The denial is overturned

 
According to the documentation submitted, this is the case of a patient with a history of hypertension, severe degenerative disease of spine and knees, urinary incontinence, major depression, osteoporosis, and dizziness.  She has a history of falls and is observed to have unsteady gait. According to the Uniform NYS (New York State) Comprehensive Health Assessment (UAS), the patient lives alone. She is totally dependent for meal preparation, shopping and housekeeping   She requires extensive assistance for bathing and weight bearing. She walks with a walker but needs assistance for weight bearing. The patient and her doctor have requested 12 hours per day 7 days per week of personal assistance service (PAS). The insurer approved a reduction from the request to 6 hours per day 7 days per week leading to the external review.
 
This is an elderly adult with chronic medical problems including hypertension, severe degenerative disease of spine and knees, urinary incontinence, major depression, osteoporosis, and dizziness. The patient lives alone.  She needs maximal assistance with weight bearing for walking. She is incontinent of urine increasing her risk for falls Her physician indicates she is at high risk for falls due to dizziness and balance problems.  She has fallen in the past.
  
The NYS Comprehensive Assessment form was reviewed. The patient's cognitive skills are described as basically intact except for occasional forgetfulness. She is assessed as requiring extensive assistance for all of her Instrumental Activities of Daily Living (IADL) and ADL tasks including meal preparation, ordinary housework, and shopping, dressing, bathing and needs maximal assistance for weight bearing. The hours approved assist her with the tasks listed above and for getting her ready for her intermittent doctor's appointments. She is reported to have dizziness, unsteady gait, and a history of falls.  Her doctor believes she is at high risk for falls.  She is also incontinent of urine increasing her risk of falling and sustaining a serious injury.

PAS 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 can be appropriately provided and maintained with 84 PAS hours/week. She has the means for emergency assistance. The patient also has the option of restructuring and flexibly using the all the PAS hours weekly to better maintain and meet her functional needs.  
 
The carrier's approval of 42 hours of PAS per week is not medically appropriate due to high risk of falls with injury. 

Based on the above, the insurer's denial must be overturned. 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 assistant (PCA) services 12 hours per day, 7 days per week services is substantiated.