Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Liver cancer, diabetes mellitus, osteoporosis, polyosteoarthritis, and anemia.

Treatment:  Personal Care Aide (PCA) services: 12 hours per day, 5 days per week; 6.5 hours per day, 2 days per week - for a total of 73 hours per week.

The insurer denied coverage for personal care aide (PCA) services: 12 hours per day, 5 days per week; 6.5 hours per day, 2 days per week - for a total of 73 hours per week.  
The denial is overturned.

The elderly female patient has experienced functional decline associated with several medical conditions. The patient lives alone and receives assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) from personal care aide (PCA) services; currently 42 hours per week. The patient also receives some informal help from her son. The patient has chronic kidney disease and has been receiving outpatient dialysis 4 times per week. The patient's son reported the PCA accompanies the patient to dialysis and the remaining PCA service time is very limited for the rest of the day to assist patient with other daily care needs at home. The patient also attends social day care 2 days per week. The son (as patient designee) requested an increase of PCA services to 12 hours per day, 5 days per week and 6.5 hours per day, 2 days per week; total of 73 hours per week, which was denied. External appeal was requested.

The most recent (and only) UAS (uniform assessment system) provided was reviewed. The functional status report for IADLs indicate the patient needs maximal assistance for meal preparation, ordinary housework, shopping; extensive assistance for stairs, transportation; limited assistance for managing finances; supervision for managing medications; setup help for phone use. For ADLs, the patient needs maximal assistance for toilet use; extensive assistance for bathing, dressing lower body, bed mobility; limited assistance for walking, locomotion, toilet transfer; setup help for personal hygiene, dressing upper body, and eating.

The patient's cognitive status, as noted in the UAS, is oriented x 3. Decision making for daily tasks was described as modified independence (some difficulty in new situations). It was noted the patient is forgetful, with short term memory problems. She needs reminders for some daily activities (e.g., medications). She is able to verbalize an emergency plan and express her needs. Communication for expression and comprehension was noted as clear. Based on the UAS report, it appears the patient's need for assistance with daily activities is primarily due to physical rather than cognitive decline.

The patient has significant functional impairment and needs various levels of assistance for all daily activities throughout the day. The son requested PCA 12 hours per day, 5 days per week; and 6.5 hours per day, 2 days per week (request for less hours 2 days per week appears to be with consideration of the time the patient is at social day care, and/or possibly when informal help is available). The additional PCA hours would extend the time the patient can receive ADL and IADL assistance each day.

Recommendation is given to approve Personal Care Aide services Level 2: 12 hours per day, 5 days per week; 6.5 hours per day, 2 days per week; total of 73 hours per week. 

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 the increase in personal care aide (PCA) services: 12 hours per day, 5 days per week; 6.5 hours per day, 2 days per week - for a total of 73 hours per week is overturned. Medical Necessity is substantiated.