Appeal type: Medical necessity
Decision: Overturned

Diagnosis: history of heart failure (HF), coronary heart disease, diabetes, benign prostatic hypertrophy (BPH), hypertension

Treatment: personal care aide (PCA) level 2, 6 hours per day, 7 days per week for a total of 42 hours per week

The insurer denied coverage for personal care aide (PCA) level 2, 6 hours per day, 7 days per week for a total of 42 hours per week

The denial is overturned

The patient is male and has significant functional limitations, but he may still have interest in some activities during the day that require mobility at home, and possibly going outside. For the patient to safely and properly perform mobility related activities, he needs help. Limiting the help, he receives during the day also limits his participation in activities of interest he may have in or outside his home.  The patient was receiving assistance through personal care aide (PCA) services 26 hours per week. The patient requested (via designee) increase in PCA services to 42 hours per week. On initial review, request was denied, but the insurer increased PCA services to 28 hours per week

The most recent UAS (Uniform Assessment System) provided for review was done. The functional status report for instrumental activities of daily living (IADLs) indicates the patient needs maximal assistance for meal preparation, ordinary housework, shopping; extensive assistance for managing finances and medications, transportation, stairs, equipment management; limited assistance for phone use. For activities of daily living (ADLs), the patient needs extensive assistance for bathing, dressing upper/lower body, toilet use; limited assistance for personal hygiene, walking, locomotion, transfer toilet, bed mobility; supervision for eating.

The patient has significant limitations with mobility. The UAS reports patient has difficulty standing up without assistance, which includes transfers from chair, toilet, bed. Appealer's comments reported patient is unable to get out of bed unassisted; and as previously noted, he needs assistance with toilet transfer. The UAS and physician's letter report patient has difficulty walking, with slow unsteady gait. The UAS reported use of cane; the appealer reported patient uses a walker. The UAS reports limited assistance for walking, but the patient has multiple symptoms that can vary in frequency and severity, including back and lower extremity pain, dizziness, shortness of breath, fatigue. When these symptoms are worse, the patient may need more support during ambulation.

There were no recent falls reported in the UAS, but the physician reported history of (h/o) falls. The patient's risk factors for falls include: unsteady gait, lower extremity pain, diabetic neuropathy lower extremities, cognitive decline, dizziness/vertigo, weakness, fatigue, h/o falls. Few, if any, interventions can prevent all falls; but the purpose of fall assessment is to identify risk, and when necessary, develop a plan to decrease the occurrence of falls. When people with physical and/or cognitive impairment live alone, they often have no choice but to attempt various daily tasks even if they do not feel secure about their ability to perform the activity alone. In this case, the patient has difficulty with mobility. When the aide is present, the patient has help moving around the home, including transfers and walking. When the patient is alone, he can only rely on his walker, which may not be sufficient. A caregiver can provide stability and, when needed, weight-bearing support. It is reasonable to expect that it is less likely the patient will fall when he has a caregiver present to assist with mobility.

Assistance from informal caregivers is voluntary as per NYS (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 necessary assistance for daily activities, including activities that occur at various and unscheduled times throughout the day.  Depending on availability of informal help, it may be necessary to split PCA 6 hours per day to maximize benefit of increased PCA hours.

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

The insurer's denial of coverage for personal care aide (PCA) level 2, 6 hours per day, 7 days per week for a total of 42 hours per week is overturned. Medical Necessity is substantiated.