Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back and hip pain, Fatigue, Dyspnea

Treatment: Personal care aide (PCA) services 8 hours per day, 7 days per week for a total of 56 hours per week

The insurer denied coverage for personal care aide (PCA) services 8 hours per day, 7 days per week for a total of 56 hours per week

The denial is overturned

This patient has experienced functional decline associated with various medical conditions and needs help with daily activities. The patient lives in an apartment with two roommates. The only informal helper identified in the Uniform Assessment System for New York (UAS) is the patient's brother who does not live locally and provides some help with Instrumental Activities of Daily Living (IADLs). The patient relies primarily on personal care aide (PCA) services for assistance with Activities of Daily Living (ADLs) and IADLs; the patient is currently receiving PCA services 36 hours per week. The patient requested increase of PCA services to 56 hours per week, which was denied. External appeal was requested.

The most recent UAS provided for review showed the functional status report for IADLs indicates the patient is totally dependent for ordinary housework; the patient needs maximal assistance for meal preparation, shopping, transportation, stairs; limited assistance for managing medications and finances; setup help for phone use. For ADLs, the patient needs maximal assistance for toilet use; extensive assistance for bathing, dressing lower body, transfer toilet, walking, locomotion; limited assistance for personal hygiene, dressing upper body, bed mobility; setup help for eating.

The records indicate the patient has chronic pain. The UAS and physician's letter indicate the patient has osteoarthritis and sciatica. UAS reports lower back, hip, and shoulder pain; patient reported pain is exacerbated by movement. The UAS also reported patient has limited range of motion (ROM) of upper and lower extremities, suggesting more extensive joint involvement from arthritis. 

The aide's letter reported it is very painful for the patient to stand for more than 5 minutes, which limits the patient's ability for food preparation/service and other household tasks that require prolonged standing.  The patient has shoulder pain which can affect ADLs (e.g., bathing, dressing, personal hygiene, toilet use) and IADLs (e.g., household tasks) that depend on shoulder function/ROM.

Mobility problems can have various adverse effects on the patient's daily function, health, and safety. The patient has slow unsteady gait; contributing factors include low back and hip pain, right foot nerve damage, fatigue, dyspnea. When a caregiver is not present, the walker is the patient's primary source of support and stability, which may not be sufficient. When the patient's symptoms are worse (e.g., pain, fatigue, dyspnea), increased effort is needed to move even short distances in the house; the patient's fall risk is greater and difficulty with mobility may discourage the patient from engaging in activities around the home.

Considering the patient's medical history and functional impairments, caregiver assistance for ADLs and IADLs is medically necessary at various times throughout the day from morning to evening to help maintain the patient's health, safety and comfort, e.g., help prevent adverse events such as skin damage (due to inadequate cleaning after toileting), and falls/household accidents; help ensure timely and appropriate meals consistent with the patient's medical conditions (e.g., diabetes mellitus); assist patient with pain relief (e.g., medications). Assistance with mobility can help the patient maintain some involvement in activities of interest in and outside the home.

Based on the above, the insurer's denial must be reversed. 

The medical necessity for personal care aide (PCA) services 8 hours per day, 7 days per week for a total of 56 hours per week is substantiated.