Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, osteoarthritis, dementia. 
Treatment: Personal Care Aide (PCA) Level 2 Services at 10 hours per day, 7 days per week for a total of 70 hours per week. 

The insurer denied coverage for PCA Level 2 Services at 10 hours per day, 7 days per week for a total of 70 hours per week. 

The denial is overturned. 

This is a female patient who has several chronic health conditions associated with functional impairment. She has a past medical history of Parkinson's disease, osteoporosis, osteoarthritis, dementia, cervicogenic headache, restless leg syndrome, gait disorder and insomnia. The patient needs assistance with most daily activities and receives Personal Care Aide (PCA) services 31.5 hours per week, 4.5 hours per day. Uniform Assessment System (UAS) documentation indicates the patient has no informal helpers. The patient's daughter requested an increase of PCA services to 70 hours per week. 

The UAS indicates the patient is totally dependent or needs maximal assistance for most instrumental activities of daily living (IADLs), except transportation (extensive assistance) and phone use (setup help). For activities of daily living (ADLs), the patient needs extensive assistance for bathing and lower body dressing; and limited assistance for most other ADLs, except eating and bed mobility (setup help only). The previous UAS noted less assistance was needed for bathing and lower body dressing (limited assistance); other ADLs were the same as noted in the more recent UAS. 

Considering the patient's medical history and functional status, it is apparent the patient needs some level of assistance with all daily activities; and with no informal help available, she is dependent on personal care services for assistance with IADLs and ADLs. This includes preparation and service of all 3 meals each day to ensure the patient is not skipping meals due to inability to prepare/serve a meal, or forgetting to eat. Reminders and supervision of her medications at various times of the day will increase medication safety. She needs assistance for bathing daily; and personal hygiene and dressing in the morning and evening. Assistance is needed for toileting and incontinence care which occurs at various unscheduled times throughout the day, to help prevent skin damage due to inadequate cleaning after toileting or incontinence; and help prevent urinary tract infections, especially from bowel incontinence. The patient's mobility is impaired due to arthritis and Parkinson's disease and she needs assistance with transfers and walking around her home to help decrease occurrence of falls. With cognitive impairment and poor safety awareness, she most likely needs some verbal cueing/prompting in addition to physical assistance to ensure safe performance of mobility and other ADLs. 

With consideration of all the issues affecting the patient's health and safety, it is medically necessary and in the patient's best interest to have caregiver assistance during morning through evening hours when the patient is most actively involved in daily activities and mobility around her home. Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at various and unscheduled times through the day. 
 
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 requested PCA Level 2 Services at 10 hours per day, 7 days per week for a total of 70 hours per week is overturned. Medical necessity is substantiated.