Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive decline; depression; chronic pain and decreased mobility; obesity; heart failure; asthma; fatigue; dyspnea; and incontinence.
Treatment: Personal Care Aide (PCA) Level 2 Services of 14 hours per day, 6 days per week; 13 hours per day, 1 day per week for a total of 97 hours per week.

The insurer denied coverage for Personal Care Aide (PCA) Level 2 Services of 14 hours per day, 6 days per week; 13 hours per day, 1 day per week for a total of 97 hours per week.  The denial is overturned. 

This is a female patient who has substantial functional impairment associated with various medical conditions. The patient's living situation is unclear. Some records indicate the patient lives with daughter, and some indicate she lives alone. The patient currently is approved for personal care aide (PCA) services 7 hours per day, 6 days per week; 6.5 hours per day, 1 day per week; total of 48.5 hours per week. There are 2 informal caregivers identified in the Uniform Assessment System (UAS) report; both identified as child or child-in-law. The patient (via designee) requested an increase of PCA services to 97 hours per week.  

The functional status report indicates patient needs high level of assistance (maximal or extensive assistance; or total dependence) for all instrumental activities of daily living (IADLs) except phone use (supervision). She needs maximal assistance for most activities of daily living (ADLs) except: walking/locomotion, eating (extensive assistance). The patient's medical history includes possible contributing factors to her functional decline such as: cognitive decline; depression; chronic pain and decreased mobility; obesity; heart failure; asthma; fatigue; dyspnea; and incontinence. 

Based on the available information, including the UAS, the physician's letter and available medical records, it appears the patient is at risk for adverse health and safety events if she does not have adequate assistance with various daily activities, including: walking and transfers (falls/injuries); toileting and incontinence care (skin damage); bed mobility (pressure ulcers; lack of adequate pain relief). Therefore, it is medically necessary and in the patient's best interest to have caregiver assistance available throughout the day and night. This is not for stand-alone safety supervision. There is sufficient information to support the need for assistance with all routine ADLs and IADLs each day; for ADL assistance including toileting, incontinence care, transfers, and walking which occur at various and unscheduled times throughout the day and night; and assistance with bed mobility and repositioning for pressure and pain relief during the time the patient is in bed. 

The UAS indicates the patient has informal caregivers who have been providing assistance. As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary. Considering there is a request for additional PCA hours (97 hours per week; 14 hours x 6 days, and 13 hours x 1 day), it is reasonable to conclude that informal caregivers are unable to provide all the necessary help with daily activities during the current non-PCA hours. The patient advocate indicated that with PCA 97 hours per week, informal caregivers will provide assistance during the other hours of the day (10 or 11 hours per day when the PCA is not present).  When informal caregivers are unable to provide necessary care when needed on a regular basis, then personal care services are indicated to provide necessary assistance with ADLs and IADLs when needed throughout the day.

The carrier's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 14 hours per day, 6 days per week; 13 hours per day, 1 day per week for a total of 97 hours per week is overturned. The medical necessity is substantiated.