Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Personal care assistance (PCA) services, Level II, 8 hours per day, 7 days per week (Monday through Sunday), a total of 56 hours per week 

The insurer denied coverage for personal care assistance (PCA) services, Level II, 8 hours per day, 7 days per week (Monday through Sunday), a total of 56 hours per week. The denial reversed.

This patient is a female with several medical conditions resulting in functional impairment and the need for assistance with daily activities (IADLs and ADLs). The patient lives alone with help from family (daughter and sister). As per the UAS, they have been providing substantial assistance (noted as 36 hours in previous 3 days). The patient applied for personal care assistance (PCA) services and was approved for 28 hours per week. The patient (via daughter as designee) requested 56 hours per week which was denied by the insurer. 

The primary cause of the patient's disability appears to be due to rheumatoid arthritis (RA). There is limited available medical history regarding when patient was diagnosed, history of prior treatment, and specific joints affected. However, the UAS describes the patient's recent symptoms and effect on her ability to perform daily activities as follows:  Patient needs assistance with ADLs and IADLs due to pain from RA which limits her ability to raise her arms, stand up, bend, or stand for long periods of time. She has difficulty walking (slow, unsteady gait, uses cane) due to RA.  The patient has fatigue and diminished energy (which is associated with RA) to the point that she cannot complete normal daily activities.

The patient has some degree of cognitive impairment. Mini mental status exam (MMSE) score (25) suggests mild cognitive impairment. The UAS identified short term and procedural memory problem. Decision making for daily activities is impaired in certain situations and supervision is needed at those times. It was noted that this is a decline from 90 days prior to the assessment. The physician's letter includes a diagnosis of dementia, and the patient is taking memantine. Impaired cognition is an additional risk factor for functional disability and often exacerbates problems caused by other medical conditions, including arthritis. The cumulative effect of comorbidities in older people is a significant factor in the declining ability to perform daily activities.

As a result of the patient's medical conditions, she needs assistance with most ADLs and IADLs, including mobility related activities that occur throughout the day (e.g. transfers, walking, and toileting) and some supervision or assistance at all meals to ensure adequate intake. Therefore, it is medically necessary for her to have a caregiver present to provide the necessary assistance. As per NYS regulations for personal care services, assistance from informal caregivers is voluntary. It appears that the family is not able to provide sufficient hours of assistance to supplement the currently approved number of PCA hours (28 per week). Therefore, it is medically necessary for PCA services to provide assistance when informal caregivers are not available.

Personal care services level II, 8 hours per day, 7 days per week, total of 56 hours per week are approved. 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 assistance (PCA) services, Level II, 8 hours per day, 7 days per week (Monday through Sunday), a total of 56 hours per week is substantiated.  The insurer's denial is reversed.