Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia and osteoporosis.
Treatment: Personal care assistance (PCA) services 10 hours per day, 7 days per week for a total of 70 hours per week.
The insurer denied coverage for personal care assistance (PCA) services 10 hours per day, 7 days per week for a total of 70 hours per week.
The denial is overturned.

This female has experienced significant functional decline associated with several medical conditions and needs assistance with all daily activities. She lives alone. She relies on personal care assistance (PCA) services for help with ADLs (activities of daily living) and IADLs (instrumental activities of daily living). The UAS (uniform assessment system) and tasking tool report that the patient's daughter stays with her mother at night and provides some informal help; but it is unclear if the daughter is currently still providing care. The patient has been receiving PCA services 43 hours per week. The patient (via designee) requested an increase of PCA services to 70 hours per week, which was denied. An external appeal was requested.

The patient is totally dependent or needs maximal assistance for most IADLs, except phone use (extensive assistance). For ADLs, the patient needs maximal assistance for bathing, toilet use, dressing lower body; extensive assistance for personal hygiene, dressing upper body, walking, locomotion, toilet transfer; limited assistance for bed mobility; and supervision for eating.

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple medical conditions resulting in physical and/or cognitive impairment. Other factors include economic and social circumstances, (e.g., caregiver support).

MLTC (Managed long-term care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. These care needs must be considered in the determination of the patient's personal care service hours. Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have caregiver assistance for all ADLs and IADLs when needed throughout the day. Without adequate assistance, the patient is at risk for adverse health and safety events, such as falls/household accidents; skin damage due to inadequate toileting/incontinence care; malnutrition/weight loss, dehydration; inadequate pain control. 

The patient needs assistance with all IADL tasks, (including preparation and service of all meals), all routine ADLs (bathing, dressing, personal hygiene) and ADLs that occur at unscheduled, recurring times of the day, including mobility,
toileting, incontinence care, and meals. Even if the daughter is still staying with the patient at night and providing care, the patient needs more assistance with daily tasks from morning through at least early evening to complete all necessary daytime activities. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unable to provide care on a regular basis, then personal care services are indicated to provide necessary assistance for ADLs and IADLs; including ADLs that occur at unscheduled and recurring times throughout the day. Considering the patient (via designee) is requesting PCA services 10 hours per day, 7 days per week, it is reasonable to conclude that there are no informal helpers who can provide care for that period of time each day.

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 personal care assistance (PCA) services 10 hours per day, 7 days per week for a total of 70 hours per week is overturned. Medical Necessity is substantiated.