Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 diabetes mellitus, diabetic polyneuropathy, spinal stenosis, atrial fibrillation, heart failure and chronic kidney disease

Treatment personal care assistance (PCA) services 24 hours per day 7 days per week (live in)

The insurer denied coverage for personal care assistance (PCA) services 24 hours per day 7 days per week (live in)

The denial is overturned

The patient has an extensive medical history associated with functional impairment and need for assistance with daily activities. The patient was hospitalized a few months ago for meningitis and was transferred to nursing home for short term rehabilitation. Prior to discharge home, the family requested personal care assistance (PCA) services 24 hours per day, live-in; request was denied. Approval was given for PCA services 45 hours per week. The patient was discharged home. The UAS (uniform assessment system) reports patient lives on the second floor of a private house; her son and his family live on the first floor. All family members work. As per UAS, the family checks on patient twice per day, but she needs assistance for all daily activities. 

The UAS reports patient has frequent urinary and bowel incontinence. The cause of incontinence was not noted, but for people with physical impairments causing delay in arrival to the toilet, the chance of incontinence is greater (functional incontinence). For this patient, it is likely she is unable to quickly reach a toilet or even transfer to a commode without assistance; and so, this may be at least part of the cause of her frequent bladder and bowel incontinence. 

Considering the patient's medical history and functional impairments, it is medically necessary for the patient to have a caregiver present through the day and night to provide assistance with all routine daily activities (including all meals, housekeeping tasks, medications, bathing, dressing, personal hygiene), and with activities that occur at various unplanned and recurring times throughout the day and night (including walking/wheelchair, transfers, toileting/incontinence care, prn pain management). Without a caregiver to provide assistance, the patient is at risk for skin damage due to inadequate incontinence care and/or pressure; falls/injury; limited ability to help herself for pain relief; risk of aspiration; risk of inadequate nutrition and hydration.  The patient's family is not able to provide care on a regular basis, and there are no other informal caregivers identified who can consistently provide assistance to the patient for daily activities. 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 regular basis, then personal care services are indicated to provide necessary assistance for daily activities, including ADLs (activities of daily living) that occur at various and unscheduled times throughout the day and night.

The family is requesting PCA services 24 hours live-in. 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 assistance (PCA) services 24 hours per day 7 days per week (live in) is overturned. Medical Necessity is substantiated.