Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident, Dementia, Osteoarthritis. 
Treatment: Personal Care Assistance (PCA) services 8 hours per day, 7 days per week, total of 56 hours per week. 
The insurer denied coverage for Personal Care Assistance (PCA) services 8 hours per day, 7 days per week, total of 56 hours per week. 
The denial is overturned. 

This is a female with a medical history significant for other dementia, stroke/ cerebrovascular accident (CVA), depression, chronic peptic ulcer, hypertension, fecal and urinary incontinence, osteoarthritis, abnormalities of gait and mobility and wandering. The patient receives personal care assistance (PCA) services 42 hours per week. The daughter requested an increase to 56 hours per week which was denied.

The patient recently had a CVA resulting in significant functional decline from her prior level of function. Recent Uniform Assessment System (UAS) documentation indicates that the patient is now totally dependent or needs maximal assistance for all instrumental activities of daily living (IADLs). In the UAS prior, the patient needed maximal or extensive assistance for most IADLs. Recent UAS documentation indicates the patient needs maximal assistance for all activities of daily living (ADLs) except eating (extensive assistance) and bed mobility (limited assistance). A comparison of the most recent UAS to the one prior shows that the patient's functional ability for almost all ADLs declined. Additionally, the patient has a history of osteoarthritis and the UAS reports indicate joint pain. There are several potentially serious adverse consequences associated with the patient's severely limited functional status. 

There are changes reported in the patient's cognitive status. Based on a comparison of two UAS reports, it appears that the patient's cognitive status declined since the recent CVA. It is likely that cognitive impairment is a contributing factor to the patient's recent functional decline. It is also apparent that the patient's mobility and ability to perform daily activities has been severely impaired. The patient had significant functional impairment before the recent CVA and so there were other factors that contributed to functional impairment even before the recent CVA. The older UAS report includes the diagnosis of transient ischemic attack (TIA)/cerebral infarction, indicating the patient had a prior history of cerebrovascular events that may have caused functional impairment before the recent CVA. 

The patient needs caregiver assistance at various times throughout the day and night. 
Based on the available information, the level and frequency of care needed to maintain the patient's health and safety has increased within the past 1-2 months. It is clear that the patient needs more than 6 hours per day to assist with IADLs and ADLs. The patient's daughter and son-in-law have been providing care for the other hours of the day and night when the aide is not present. Caregiver assistance is voluntary as per New York State regulations for personal care services. Considering the patient's medical history and recent functional decline, it is medically necessary for the patient to have a caregiver present to provide assistance for all daily activities which may occur at multiple and various times during the day and/or at night. In this situation, personal care services are indicated to provide assistance to the patient for all necessary daily activities (IADLs and ADLs) during the time each day when informal caregiver assistance is not available. 

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

The carrier's denial of coverage for 8 hours per day 7 days per week, a total of 56 hours per week of PCA services is overturned. The medical necessity is substantiated.