Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis; diabetes mellitus type 2
Treatment: Personal care assistance (PCA) 12 hours per day 7 days per week for a total of 84 hours a week.
The insurer is denied coverage for Personal Care Assistance (PCA) 12 hours per day 7 days per week for a total of 84 hours a week. 
The denial is reversed. 

This female has extensive medical history that included hypertension, diabetes mellitus type 2, depression, anxiety, obesity, breast cancer, dyspnea, osteoarthritis, associated with significant functional impairment. The patient lives alone. She receives personal care assistance (PCA) services 5 or 6 hours per day, 5 days per week (29 hours per week). The patient's daughter and son are involved and provide some help with daily activities; but both work full time and it is not clear how much time they provide to assist their mother evenings and weekends. Request was made for PCA services 84 hours per week (12 hours per day, 7 days per week). 

The patient needs assistance with toileting and incontinence care. She has frequent episodes of incontinence; which can occur more often when she is alone, as she has difficulty standing up and walking, and so it can take longer to reach a toilet or commode. With frequent incontinence, the patient is at risk for incontinence associated skin damage (e.g. dermatitis, fungal infection). The patient has limited range of motion (ROM) of upper and lower extremities; and so she needs assistance managing clothing, hygiene, changing pads and undergarments. She needs assistance transferring on and off the toilet.  Therefore, a caregiver is needed throughout the day when toileting and incontinence care is needed. 

The UAS indicates no falls in the previous 90 days. The information provided by the physician and patient advocate indicate the patient has had recent falls; one noted to involve head trauma (contusion, swelling to eye and face). The UAS diagnosis list includes h/o falling. The patient has multiple risk factors for falls including: arthritis, chronic pain, unsteady gait, dizziness, fatigue/weakness, advanced age, incontinence, cognitive impairment, use of medications associated with increased fall risk (e.g. opioid, antihypertensive drugs, antidepressant). Falls in the elderly have a higher risk of serious injury (e.g. fractures, head trauma), increased morbidity, and increased risk of death. The patient needs assistance with mobility related ADLs as per the UAS, and this needs to be included in the patient's plan of care. The

Considering the patient's medical conditions and associated functional impairments, it is medically necessary for the patient to have a caregiver present throughout the day to provide assistance with her daily activities, including ADLs that occur throughout the day at various, unscheduled times (i.e. transfers, walking, toileting, incontinence care). Assistance is also needed at various times for prn use of medications (pain, asthma), and to ensure adequate intake of fluids. 

Personal Care Assistance 12 hours per day, 7 days per week, and total of 84 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Personal Care Assistance (PCA) 12 hours per day 7 days per week for a total of 84 hours a week is substantiated.  The insurer's denial is reversed.