Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis, Lumbar intervertebral disc displacement, Lumbar and cervical radiculopathy, Polyneuropathy.
Treatment:  Personal Care Assistant (PCA) services, 40 hours per week.

The insurer partially denied coverage for Personal Care Assistant (PCA) services, 40 hours per week.  The denial is overturned.

This is a female patient with a medical history of chronic obstructive pulmonary disease (COPD), asthma, allergy, osteoarthritis, lumbar intervertebral disc displacement, lumbar and cervical radiculopathy, gait abnormality, polyneuropathy, generalized muscle weakness, depression, anxiety, insomnia, urinary incontinence, and overactive bladder.  The patient was in a motor vehicle accident a couple years ago that resulted in chronic symptoms and functional impairment.  She lives alone and needs assistance with daily activities.  She was receiving personal care aide (PCA) services 25 hours per week.  She requested an increase to 40 hours per week, which was denied; but the insurer increased PCA services to 30 hours per week.  

Uniform Assessment System (UAS) documentation indicates that the patient needs maximal assistance for household related tasks and shopping, and she requires extensive assistance with stairs.  For activities of daily living (ADLs), the patient needs extensive assistance with bathing and lower body dressing, and she needs limited assistance for all other ADLs, except eating (setup help).  For instrumental activities of daily living (IADLs), she needs maximal assistance with meal preparation, ordinary housework and shopping, extensive assistance with stairs, limited assistance with transportation, and setup help with managing medications.  The patient has multiple diagnoses that are probable contributing factors to her functional impairment including various sources of chronic pain, including cervical and lumbar radiculopathy, osteoarthritis, and polyneuropathy. 

Considering the patient's medical history and functional limitations, it is medically necessary and in the patient's best interest for her to have caregiver assistance for ADLs and IADLs to ensure effective and safe performance of daily activities.  Assistance from informal caregivers is voluntary ,as per New York State (NYS) regulations for personal care services.  The patient may have some help from friends, but the amount of assistance provided (as per the UAS report) is not sufficient for all the patient's care needs during the hours of the day when the aide is not present.  When informal caregivers are unable to provide necessary assistance on a consistent basis during all the hours of the day that care is needed, then personal care services are indicated to provide assistance with daily activities including ADLs that occur at various times throughout the day. 

The patient (via advocate) requested PCA services 40 hours per week.  The advocate's report noted the request was for 8 hours per day, 5 days per week.  The patient needs assistance with ADLs and IADLs 7 days per week.  The advocate's letter does not explain who provides assistance to the patient the other 2 days of the week if PCA services are provided 5 days per week.  The allocation of the 40 hours should be determined with the patient to provide maximum benefit of PCA services through the week, with consideration of any informal caregiver services that may be available.

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

The carrier's partial denial of coverage for PCA services, 40 hours per week is overturned.  The medical necessity is substantiated.