Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, spinal fractures, pelvic fractures, hypertension, coronary artery disease, atrial fibrillation,

Treatment increase in Personal Care Aide (PCA) Level 2 hours to 8.5 hours per day, 7 days per week for a total of 59.5

The insurer denied coverage for increase in Personal Care Aide (PCA) Level 2 hours to 8.5 hours per day, 7 days per week for a total of 59.5

The denial is overturned

This female has significant functional impairment associated with multiple medical conditions and needs substantial assistance with all daily activities. She lives with her husband who provides some assistance with daily care. The daughter is involved but she reports that she is not able to provide regular assistance with daily care. The patient receives Personal Care Aide (PCA) services 7.5 hours per day, 7 days per week, 52.5 hours per week. 

The combined effects of these conditions can cause substantial physical impairment due to pain and weakness. Shoulder pain can limit most tasks dependent on upper extremity function, including personal hygiene, bathing, upper body dressing, toileting (patient needs maximal or extensive assistance for these ADLs [activities of daily living]). The patient's back pain may be due to arthritis and probably chronic effects from vertebral fractures. Back pain can limit mobility and any task that involves movement of the spine, such as bending for lower body dressing and bathing. Knee pain is likely due to osteoarthritis and is a common cause of impaired mobility including unsteady gait and difficulty with transfer activity.

Based on the patient's medical history and physical and cognitive impairment, it is medically necessary for the patient to have assistance with all daily activities. This includes preparation/service of 3 meals per day and assistance with eating. She needs assistance for bathing daily; personal hygiene and dressing morning and evening; toileting/incontinence care which occurs at various unscheduled times of the day and night. Patient's mobility is substantially impaired, and she needs help for transfers to/from bed/wheelchair/toilet, and for bed mobility (repositioning). MLTC (managed long-term care) policy 16.07 states that plans must assure the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. Therefore, all the patient's care needs must be considered in the determination of her PCA hours. 

Considering the patient's functional limitations, she needs care at various times throughout the day and night, including toileting, incontinence care and repositioning, as the care needs for these ADLs extend beyond daytime hours. The daughter reported that she is not able to provide care consistently on a daily basis, which leaves all the responsibility for the rest of the day and night with the husband. The available records do not identify any other informal caregivers who can provide sufficient and consistent care when the PCA is not present. As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers are unable to provide care when needed on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs (instrumental activities of daily living) when needed throughout the day and night. Considering the family is requesting additional PCA hour every morning, it is reasonable to conclude the husband is not able to provide early morning care. The husband's availability to provide assistance needs clarification in order to develop a care plan that meets the patient's care needs. 

Recommendation is given to approve Personal Care Aide services Level 2: 8.5 hours per day, 7 days per week; total of 59.5 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 an increase in Personal Care Aide (PCA) Level 2 hours to 8.5 hours per day, 7 days per week for a total of 59.5 hours per week is overturned. Medical Necessity is substantiated.