Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left foot fracture, Osteoarthritis, Cardiovascular disease. 
Treatment: Personal Care Aide (PCA) services, 12 hours per day, 7 days per week (total of 84 hours per week). 
The insurer denied coverage for Personal Care Aide (PCA) services, 12 hours per day, 7 days per week (total of 84 hours per week). 

The denial is overturned. 

This is a female patient with a medical history of hypertension, degenerative joint disease, osteoarthritis, glaucoma, coronary heart disease, congestive heart failure (CHF) and recent left foot fracture. She has various medical conditions resulting in functional impairment and requiring assistance with all daily activities. The patient lives alone with limited informal support. The patient was receiving Personal Care Aide (PCA) services 56 hours per week. The patient (via designee) requested an increase of PCA hours to 84 per week which was denied. The insurer increased PCA hours to 59.5 hours per week. 

The patient's cognitive status indicates that in certain situations her decision making for daily tasks becomes poor/unsafe. She has short term and procedural memory impairment. Her orientation is intact. The patient expresses some feelings of depression and anxiety; no treatment is noted in the medication records. The functional status from Uniform Assessment System (UAS) documentation indicates the patient was totally dependent or needed maximal assistance for all instrumental activities of daily living (IADLs), except phone use: extensive assistance. For activities of daily living (ADLs), the patient was totally dependent or needed maximal assistance for all ADLs, except eating: extensive assistance. 

Acute medical or traumatic events can cause an accelerated decline in functional ability for daily activities. The patient's medical history includes a few conditions that probably have a substantial impact on her functional status including: left foot fracture; osteoarthritis; and cardiovascular disease. There are other concerns about the patient being alone for so many hours. The patient has chronic pain. It does not appear that she has the ability to self-medicate if she has pain at night (UAS indicates maximal assistance is needed for medications). Lying in bed for so many hours with very limited ability to move can become uncomfortable, and she has no one to assist her to move to a more comfortable position. It does not appear that there is a satisfactory plan in place for pain management when the patient is alone. Considering the patient's medical history and severe functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day, to provide assistance with all scheduled tasks (IADLs, routine ADLs during the day) and ADLs that occur at unscheduled times such as toileting, incontinence care, transfers in and out of bed or chair, mobility around her home. 

The UAS indicates the patient has an informal caregiver; but the type and frequency of assistance provided appears limited. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide the patient with assistance for all necessary daily activities when needed. The maximum amount of PCA hours that can be approved from this review is limited by the number of hours requested; in this case, 84 hours per week. There is still concern regarding the patient's need for assistance with ADLs during the other 12 hours of the day. 

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

The insurer's partial denial of coverage for PCA services, 12 hours per day, 7 days per week (total of 84 hours per week) is overturned. The medical necessity is substantiated.