Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Myeloma

Treatment: Increase in Personal Care Aide (PCA) Level 2: 19 hours per day - 7 days per week - a total of 133 hours per week

The insurer denied coverage for increase in Personal Care Aide (PCA) Level 2: 19 hours per day - 7 days per week - a total of 133 hours per week

The denial is overturned

This case involves an elderly patient with a subject of review for the denial of coverage for an increase in Personal Care Aide (PCA) Level 2: 19 hours per day - 7 days per week - for a total of 133 hours per week. The patient had a uniform assessment completed. The patient reported they live alone in a 2-bedroom apartment with elevator access. The patient's diagnoses were listed as anxiety, osteoporosis, hypertension, hyperlipidemia, insomnia, multiple myeloma, atherosclerotic heart disease of native coronary artery, chronic pancreatitis, history of skin and pancreatic cancer, spondylosis, intestinal ulcer, osteoarthritis, shingles, and vitamin D deficiency. The patient was noted to be on 19 medications. The patient reported a decline in decision making but was reported to be alert and oriented (A/O) x 3. The patient required maximal assistance to total dependency with most daily tasks except for phone usage and eating in which she required supervision assistance. The patient was reported using cane, crutch, and pushing wheelchair for walking. The patient reported a decline in their activities of daily living (ADL) status and deterioration with their overall self-sufficiency. The patient reported a history of fall 31-90 days ago. The patient was reported to be frequently bladder incontinent and occasionally bowel incontinent. It was noted that the patient has less than daily bowel incontinence and daily bladder incontinence. The patient's incontinence was managed with pull-ups, liners, and chux. 

The patient's provider submitted a Letter of Medical Necessity. They noted the patient would benefit from full-time home care as the patient has become increasingly frail over the past 2-3 years. They noted the patient's gait is unsteady and at risk for falls and fractures. The patient would also benefit from assistance, especially at night to help get to and from the bathroom safely as frequently as every 2 hours to prevent the risk of sacral ulcers. They concluded that the patient lives alone and at times struggles with ADLs such as cooking and cleaning. 

In this case, the patient has diagnoses listed as anxiety, osteoporosis, hypertension, hyperlipidemia, insomnia, multiple myeloma, atherosclerotic heart disease of native coronary artery, chronic pancreatitis, history of skin and pancreatic cancer, spondylosis, intestinal ulcer, osteoarthritis, shingles, and vitamin deficiency. The patient reported a decline in her functional status as she requires hands-on assistance with most ADLs/Instrumental Activities of Daily Living (IADLs) except for phone usage and eating in which the patient needed supervision assistance. The decline in the patient's status is supported by their treating physician who noted progression of their myeloma along with complications of the therapy. 

The medical records submitted for review do support the reversal of the denial of 19 hours per day - 7 days per week - for a total of 133 hours per week of personal care aide hours. According to the records submitted, the patient reported a decline in the patient's functional status and cognition supported by their provider. Thus, the denial of the request for an increase in personal care aide hours to 19 hours per day - 7 days per week - for a total of 133 hours per week is reversed. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in Personal Care Aide (PCA) Level 2: 19 hours per day - 7 days per week - a total of 133 hours per week is substantiated.