Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident

Treatment: Personal Care Aide (PCA) Level 2: 6 hours per day, 6 days per week, for a total of 36 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 6 hours per day, 6 days per week, for a total of 36 hours per week.

The denial is overturned. 

This is a male patient status post cerebral vascular accident (CVA), who received acute rehabilitation then returned home after discharge. The patient lives with his mother. Prior to the CVA, the patient was receiving personal care aide (PCA) services 4 hour per day, 5 days per week. The patient requested increase of PCA services after the CVA to 6 hours per day, 6 days per week. Uniform Assessment System (UAS) documentation identifies a decline in functional status with several activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient's mobility is impaired, with the UAS reporting the patient has unsteady gait and needs contact guidance for walking. He needs limited assistance for transfer on/off the toilet. It was also noted the patient often has difficulty moving to a standing position unassisted, which may be at least partly due to his knee deformity. He needs extensive (weight-bearing) assistance with stairs. This is a significant issue, as the patient lives in a 4th floor walk-up apartment (not handicap accessible). Without assistance, he is either unable to use the stairs; or if he attempts to use the stairs, this would be a potentially dangerous activity, with high risk for falls. 

There were several significant changes in the patient's functional status comparing two UAS reports (bathing, lower body dressing, walking, stairs, and toilet transfer). The patient previously needed supervision for walking. He now needs hands-on assistance for stability with ambulation. The same is noted for transfer on and off the toilet; and he often needs assistance to stand up, even for non-toilet transfers. The more recent UAS identifies a decline in functional status with several ADLs and IADLs. The patient's mobility has declined and he is at risk for falls and serious injury if he does not have assistance for walking and stairs. He also needs assistance with transfers and performing household tasks. It is medically necessary for the patient to have a caregiver present for a more extended period of time each day to help him adapt to his current level of function in a safe manner.

Considering the patient is requesting PCA services 6 hours per day, 6 days per week, it is reasonable to conclude that there are no informal caregivers to assist him during the requested hours and days. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. The patient has no informal caregivers identified who can provide the level of assistance he needs on a consistent basis 6 days per week. In the absence of informal caregivers who can assist with daily care on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed. The additional hours of PCA assistance each day will extend the time the patient can effectively and safely move in his home and outside environment; and help him remain involved in daily life.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for the requested PCA Level 2: 6 hours per day, 6 days per week, for a total of 36 hours per week is substantiated. The insurer's denial is overturned.