Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertension, hyperlipidemia, low vision right eye category 2, blindness left eye category 5, glaucoma, polyneuropathy.
Treatment: Personal Care Aide services.
The insurer is denied coverage for personal care aide services.  The denial is reversed. 

This patient was a male with extensive medical history including degenerative disc disease, lumbar and cervical radiculopathy, lumbar spinal stenosis, cervical spine cord compression, multiple disc herniations, s/p lumbar laminectomy, and then recent compression of C7 nerve root, polyneuropathy.  These problems have caused substantial pain, weakness and disability.  He lives alone with limited informal caregiver assistance.  He has been receiving personal care aide (PCA) services 7 hours per day, 7 days per week.  He requested an increase of PCA hours to 10 hours per day, 7 days per week, which was denied.  An external appeal was requested. 

The patient needs extensive assistance for most ADLs (except bed mobility, eating). Transfers, toileting, walking/locomotion occur throughout the day.  In addition, the patient's evening activities before bed (change of clothes, personal hygiene, toileting, transferring into bed) all require extensive assistance.  With 7 hours of PCA services per day, the patient needs to perform ADLs later in the day without assistance (after the aide leaves for the day).  It was determined by the insurer that the patient needs PCA services to help with ADLs during 7 hours of the day.  However, the insurer's denial letter does not explain how the patient can effectively and safely manage most of the same ADLs during the remaining hours of the day when the he is alone.  The insurer's letter noted patient has family support; but the UAS does not identify any family member or other informal caregiver, who provides care on a regular basis after the aide leaves each day.

The patient has a complex medical history that has resulted in substantial physical limitations for basic daily activities and places him at high risk for falls/household accidents and injury.  The UAS identifies the patient's need for assistance with IADLs and ADLs.  It is apparent from the physician letters and UAS description of the patient's symptoms and physical limitations that he needs assistance throughout the day.  Therefore, it is medically necessary for the patient to have caregiver assistance for ADLs that occur throughout the day at various and unscheduled times (i.e. transfers, walking, toileting) and some of the late day tasks before going to bed (e.g. change of clothes, evening hygiene).

The patient has very limited informal support.  There is one relative who provides some assistance, but there is no documentation to indicate that this relative or any other caregiver can be available for the patient during more extended hours of each day on a regular basis.  Assistance from informal caregivers is voluntary, per NYS regulations for personal care services.  Receiving assistance from informal caregivers for multiple hours per day does not appear to be an option for the patient.  Therefore, it is medically necessary for personal care services to provide the patient with assistance for a more extended period of the day in order to accommodate his need for assistance with ADLs which occur throughout the day. 

Personal Care Aide (PCA) services, 7 days per week, 10 hours per day, 70 hours per week is medically necessary.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the requested increase in Personal Care Aide services to 7 days per week 10 hours per day (or 70 hours per week) is substantiated.  The insurer's denial is reversed.