Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary heart disease, heart failure, diabetes, hypertension, gastroesophageal reflux disease (GERD),
Treatment is PCA 84 hours per week, 12 hours per day, 7 days per week
The insurer denied coverage for PCA 84 hours per week, 12 hours per day, 7 days per week
The denial is overturned

This patient has significant functional impairment associated with several medical conditions and needs assistance with all daily activities. The patient lives alone. She has some informal help from her niece, but the patient primarily depends on personal care aide (PCA) services for assistance with all ADLs (activities of daily living) and IADLs (instrumental activities of daily living). The patient was receiving PCA services 42 hours per week. The patient's niece (as patient designee) requested an increase of PCA services to 84 hours per week which was denied; but on appeal, PCA services were increased to 52.5 hours per week; 7.5 hours per day, 7 days per week.

The most recent UAS (uniform assessment system) form provided was reviewed. The functional status report for IADLs indicated the patient is totally dependent for housework, managing finances, stairs, transportation; she needs maximal assistance for meal preparation, shopping, managing medications; limited assistance for phone use. For ADLs, the patient is totally dependent for dressing lower body, toilet use; she needs maximal assistance for bathing, walking, locomotion, transferring to the toilet; extensive assistance for personal hygiene, dressing upper body, bed mobility, and eating. 

Considering the patient's medical history and functional status as noted in the available records, it is apparent that the patient needs substantial assistance for all IADLs and 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 all daily activities. The patient needs assistance for routine household tasks, and preparation/service of all 3 meals; assistance with eating all meals; routine morning and evening ADLs (e.g., bathing, dressing, personal hygiene); and unscheduled/recurring activities, including toileting related tasks/incontinence care; out-of-bed mobility (transfers, walking). Without adequate assistance, the patient is at high risk for adverse health and safety events, e.g., skin damage due to incontinence; nutritional decline, and falls/injury.

The only informal caregiver identified in the UAS is the patient's niece. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. Considering the request for PCA services is for 12 hours per day, 84 hours per week, it is reasonable to conclude that there are no informal caregivers available for this amount of time every day to help the patient with daily activities. When informal caregivers are not available to provide necessary care for daily activities, then personal care services are indicated to provide assistance for IADLs and ADLs when needed throughout the day. The patient has substantial functional impairment and needs assistance for all daily activities from morning until she goes to sleep at night. The patient will benefit from increase of PCA services to 12 hours per day. Re-assessment will determine whether this plan adequately meets the patient's daily care needs.

Recommendation is given to approve Personal Care Aide services Level 2: 12 hours per day, 7 days per week; total of 84 hours per week.

The insurer's denial of coverage for Personal Care Aide (PCA): 12 hours per day - 7 days per week - for a total of 84 hours is overturned. Medical Necessity is substantiated.