Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Legally blind, cognitive impairment due to vascular dementia, depression, insomnia, fatigue, limited range of motion (ROM), reduced mobility, hypertension, coronary artery disease

Treatment: Personal Care Aide (PCA) Level II PCS of 12 hours per day, 7 days per week, for a total of 84 hours per week

The insurer denied coverage for PCA Level II PCS of 12 hours per day, 7 days per week, for a total of 84 hours per week

The denial is overturned

The patient is a female with a medical history of legally blind, cognitive impairment due to vascular dementia, depression, insomnia, fatigue, limited range of motion (ROM), reduced mobility, hypertension, coronary artery disease (CAD), peripheral vascular disease (PVD)/claudication, hyperlipidemia, diabetes mellitus (DM) II with neuropathy, iron deficiency anemia, constipation, pain due to osteoarthritis of knees, lower back pain (LBP) due to lumbar degenerative disc disease, osteoporosis, overactive bladder (OAB), and urinary incontinence.  The patient has poor activity tolerance and repeated falls.  The patient needs assistance with Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs).  Recommendation is given for home care 12 hours daily, 7 days per week.

Uniform Assessment System (UAS) interview was performed via telephone due to 2019 Novel Coronavirus.  The most recent UAS provided for review was done a few months ago. Functional status indicates maximal assistance or total dependence for most IADLs; except managing finances, medications, phone (extensive assistance).  For ADLs, the patient's out of bed mobility is by wheelchair; she no longer walks (not clear when this occurred; she was walking with walker and extensive assistance at the time of the UAS).  Maximal assistance is needed for bathing, lower body dressing, toilet transfer and use; extensive assistance is needed for personal hygiene, upper body dressing, bed mobility, eating.

Considering the patient's medical history and substantial functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present to provide assistance with ADLs and IADLs; including ADLs that occur at various and unscheduled times through the day (e.g. toileting, incontinence care, transfers between bed and wheelchair, wheelchair mobility).  Without adequate caregiver assistance, the patient is at risk for adverse health and safety events including skin injury and infection (inadequate toileting/incontinence care); falls/injury (attempt to get out of bed when alone); insufficient response to hypoglycemia (patient with limited physical and cognitive ability to respond).

Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance to the patient for daily activities, including ADLs that occur at various and unscheduled times throughout the day.

The maximum amount of hours that can be approved from this review is limited by the number of hours requested; in this case 84 hours per week.  84 hours per week Personal Care Aide Level II, PCS Level II Basic-15 minutes is medically necessary. 

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

The insurer's denial of coverage for the requested PCA Level II Personal Care Services (PCS) of 12 hours per day, 7 days per week, for a total of 84 hours per week is reversed. Medical necessity is substantiated.