Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Retinal detachment, Carpal tunnel syndrome, Osteoporosis

Treatment: Personal Care Aide (PCA) services, 12 hours per day, 7 days per week (84 hours per week)

The insurer denied coverage for Personal Care Aide (PCA) services, 12 hours per day, 7 days per week (84 hours per week).

The denial is overturned.

This is a female patient with several medical conditions contributing to functional impairment for daily activities. She has a medical history of anxiety, major depressive disorder, diabetes mellitus, dementia, osteoporosis, carpal tunnel syndrome, hypertension, falls, transient ischemic attack (TIA), insomnia, detached retina and urinary incontinence. The patient was approved for Personal Care Aide (PCA) services 6 days per week, 8 hours per day (48 hours per week). The patient (via designee) requested PCA services 7 days per week, 12 hours per day (84 hours per week), which was denied. 

Uniform Assessment System (UAS) documentation indicates that the patient is totally dependent on caregiver support for all household related tasks, shopping, and finances. She also needs extensive assistance for medications, phone use, transportation, and stair climbing. The patient needs extensive assistance for several activities of daily living (ADLs) including bathing, walking, toileting, and lower body dressing. She needs limited assistance for personal hygiene, upper body dressing, eating, and bed mobility. The UAS indicates that the patient has short term and procedural memory impairment and poor/unsafe decision making for daily tasks. Functional decline is an expected consequence of dementia as cognitive impairment progresses. The UAS also indicates that the patient has frequent intermittent pain; noted as arthritis pain affecting her hands and shoulders which interferes with her ability to perform manual tasks and activities that require range of motion of shoulder (e.g. putting on a blouse). These upper extremity impairments affect most ADLs. The patient also has carpal tunnel syndrome, which causes pain, numbness and weakness, affecting use of the hands. The patient was diagnosed with retinal detachment resulting in vision loss of right eye. Loss of sight in one eye can affect depth perception, judging distance or moving objects. With dementia, it is likely the patient has difficulty learning to adapt and adjust to the changes in her vision, and is probably a significant factor in the patient's functional decline. 

The patient's daughter is the only informal caregiver identified in the UAS report. She has been providing assistance to her mother when the PCA is not present; and this includes one full day of the week, as PCA hours are approved for only 6 days per week. Assistance from informal caregivers is voluntary as per NYS regulations for Personal Care Services. The patient has substantial functional deficits, including vision loss. The patient needs assistance for all daily activities as a result of her functional impairment. Therefore, it is medically necessary for a caregiver to be present throughout the day and night to provide assistance with all daily activities, including ADLs that occur at various unscheduled times. The daughter can provide care at night, but is requesting PCA services 12 hours per day, 7 days per week when she is not available. When informal caregivers are not able to provide care on a consistent basis, Personal Care Services are indicated to provide assistance to the patient for all daily activities when needed throughout the day.

PCA services, 7 days per week, 12 hours per day, 84 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for PCA services, 12 hours per day, 7 days per week (84 hours per week) is substantiated. The insurer's denial is overturned.