Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus.
Treatment: Personal Care Assistant (PCA) level 2: 12 hours per day, 7 days per week for a total of 84 hours per week.
The insurer denied coverage for PCA level 2: 12 hours per day, 7 days per week for a total of 84 hours per week.
The denial is overturned.

The patient is a male with an extensive medical history of cardiovascular disease, diabetic neuropathy, chronic kidney disease, and osteoarthritis associated with functional impairment. He needs assistance with most daily activities. The patient lives alone and receives PCA services 56 hours per week, 8 hours per day. The patient has some informal support from a neighbor and relative, but he is alone most of time when the PCA is not present. The patient's physician and granddaughter reported that the patient has had several falls. 

The patient has multiple medical conditions causing pain, fatigue and weakness. The cumulative effect of these symptoms results in substantial physical burden for performance of basic daily activities. In addition to the physical stress, the effort needed to perform routine tasks and move around the home can also result in anxiety and depressed mood. As per the Uniform Assessment System (UAS), the patient did not report feeling depressed, but it was noted that the patient was feeling anxious due to living alone. There are many concerns that cause elderly people to experience anxiety. For this patient, it is likely that the difficulty he has with most daily activities, and his history of multiple falls has contributed to his anxiety about living alone. Having caregiver assistance to help relieve some of the physical burden of daily physical function may also help alleviate some of the anxiety associated with performing daily tasks alone, and the fear of falls, accidents and injury.

Considering the patient's medical history and functional status, it is apparent that the patient needs considerable assistance for most Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs). Therefore, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day to provide assistance for daily activities. The patient needs assistance for IADLs and ADLs that occur at various scheduled and unscheduled times throughout the day. This includes routine household tasks, and preparation/service of all 3 meals; routine morning and evening ADLs (e.g. bathing, dressing, personal hygiene); and unscheduled activities, including toileting related tasks and out-of-bed mobility (transfers, walking). Without adequate assistance, the patient is at high risk for adverse health and safety events, e.g. falls/injury, nutritional decline, hypoglycemia (if patient misses meals when alone). 

The informal caregivers identified in the UAS (neighbor and relative) provide some assistance with ADLs and IADLs but it does not appear this occurs for extended periods of time on a daily basis. 

Personal Care Aide Level 2: 12 hours per day, 7 days per week; total of 84 hours per week are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the requested personal care aide (PCA) level 2: 12 hours per day, 7 days per week for a total of 84 hours per week is reversed. Medical necessity is substantiated.