Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, transient cerebral ischemic attack, hypertension, benign paroxysmal vertigo. 
Treatment: Increase in Personal Care Aide (PCA) services: 7 hours per day, 7 days a week, a total of 49 hours per week
The insurer denied coverage for increase in Personal Care Aide (PCA) services: 7 hours per day, 7 days a week, a total of 49 hours per week. 
The denial is overturned. 

This patient is a male has several medical conditions causing functional impairment and decline in ability to perform daily activities. The patient lives alone. He receives some informal help from his daughter, but he mostly relies on personal care aide (PCA) services for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). He has been receiving PCA services 35 hours per week (5 hours per day). The patient reported further decline in health and increased difficulty performing daily tasks. The patient (via designee) requested increase of PCA services to 49 hours per week (7 hours per day), which was denied. 

The most recent Uniform Assessment System (UAS) provided for review was done. Functional status for IADLs indicates patient is totally dependent for ordinary housework; he needs maximal assistance for meal preparation, managing medications, shopping; extensive assistance for managing finances, stairs, transportation; limited assistance for phone use. For ADLs, the patient needs extensive assistance for bathing, personal hygiene, dressing upper/lower body, transfer toilet, walking, locomotion, bed mobility; limited assistance for toilet use; setup help for eating. ADL changes UAS include: personal hygiene, transfer toilet: limited assistance (extensive assistance toilet use: set up help (limited).

As per the UAS, the patient needs assistance for all aspects of toileting. He needs extensive assistance walking to the bathroom. During daytime hours, a commode is not an adequate solution, as he is most likely not in bed, or sitting in one location all day. The patient needs weight-bearing assistance with toilet transfer; and so, when he is alone, there is increased risk of falls during transfer on/off the toilet. When older people fall in the bathroom, there is increased risk of injury. 

In order to facilitate safe, effective completion of toileting tasks, and help prevent complications related to falls and incontinence, the patient needs to have a caregiver available to assist with toileting and incontinence care for a more extended period of the day. When the aide is present, the patient has assistance with transfers and walking around the home. When he is alone, he can only rely on his walker, which may not be sufficient, especially when symptoms are worse (e.g., pain, dizziness, weakness, fatigue). As per UAS, the patient has had multiple falls, including injury (rib fracture last year). 

As per UAS, the patient's daughter is the only informal helper. Information was inconsistent; in one section it was noted she assisted with only IADLs; other comments noted assist with ADLs and IADLs. The daughter's current ability to provide care is not known; but considering the request for PCA services is for 49 hours per week, 7 hours per day, it is reasonable to conclude there are no informal helpers who can provide care during that period of time each day.  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 regular basis, then personal care services are indicated to provide necessary assistance for daily activities, including ADLs that occur at unscheduled and recurring times throughout the day. 

Based on the above, the insurer's denial should be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for increase in Personal Care Aide services (PCA): 7 hours per day, 7 days a week, a total of 49 hours per week services is substantiated.