Appeal type: Medical necessity
Decision: Overturned

Diagnosis: coronary heart disease, stroke, Parkinson's disease
Treatment: personal care aide (PCA) level 2: 10 hours a day - 7 days a week - a total of 70 hours per week
The insurer denied coverage for personal care aide (PCA) level 2: 10 hours a day - 7 days a week - a total of 70 hours per week.
The denial is overturned.
 
This elderly patient has substantial functional impairment associated with several medical conditions and needs assistance with all daily activities. The patient lives with her husband. The recent Uniform Assessment System (UAS) indicates husband and son are informal helpers, but most assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) is provided by personal care aide (PCA) services. The patient was receiving PCA (personal care aide) 48 hours per week. The insurer's final denial letter included report from the patient that she needs additional assistance for her personal care needs; noting that her husband is unable to assist her due to his medical condition. The patient (via designee) requested PCA (personal care aide) services 70 hours per week, 10 hours per day which was denied; but the insurer increased PCA (personal care aide) services to 59.5 hours per week, 8.5 hours per day. An external appeal was requested.

The most recent UAS (Uniform Assessment System) provided for review was reviewed. The functional status report for IADLs (instrumental activities of daily living) indicates patient is totally dependent for ordinary housework, stairs, transportation; she needs maximal assistance for meal preparation, shopping, managing medications; limited assistance for phone use, managing finances. For ADLs (activities of daily living), the patient is totally dependent for bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use; she needs maximal assistance for personal hygiene, dressing upper body, bed mobility, eating.

The UAS (Uniform Assessment System) indicates the patient needs substantial assistance for most daily activities, with total dependence for multiple IADLs (instrumental activities of daily living) and ADLs (activities of daily living). 

The records indicate the patient has Parkinson's disease (PD). Motor symptoms of PD include bradykinesia, rigidity, postural instability, unsteady gait, tremor; all of which can adversely affect ability to perform daily activities.  Non-motor symptoms include autonomic dysfunction (e.g., blood pressure changes including orthostatic hypotension, bowel and bladder dysfunction); and (as previously noted) cognitive impairment and mood disorders. Other symptoms include dizziness, fatigue, pain, sleep disturbances. Falls are common due to effects of motor and non-motor symptoms. 

The UAS (Uniform Assessment System) indicates the patient requires substantial assistance for all daily activities; and comparison of the UAS reports indicate almost all ADLs (activities of daily living) declined. The effects of the patient's poor functional status place her at high risk for adverse consequences.

The patient requires substantial assistance for ADLs (activities of daily living) and IADLs (instrumental activities of daily living) throughout the day. It is medically necessary for the patient to have a caregiver from morning to evening to ensure all ADLs and IADLs are completed properly and safely, including routine IADLs (meal preparation/service, medications, household tasks); routine ADLs (bathing, dressing, personal hygiene, eating); and ADLs (activities of daily living) that occur at unscheduled and/or recurring times of the day including toileting/incontinence care; out of bed mobility; repositioning. Assistance is necessary to help maintain skin integrity; decrease risk of infection (e.g., urinary tract infection (UTI)); facilitate safe, adequate food and fluid intake; help decrease occurrence of falls.

Recommendation is given to approve Personal Care Aide services Level 2: 10 hours per day, 7 days per week; total of 70 hours per week.

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 aide (PCA) level 2: 10 hours a day - 7 days a week - a total of 70 hours per week is substantiated.