Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal Care Assistance (PCA) 50 hours a week
The insurer denied the Personal Care Assistance (PCA) 50 hours a week.
The denial was overturned.

This is a male patient with a history of hypertension, osteoarthritis, chronic gout left knee, hypercholesterolemia, leukemoid reaction. The patient reportedly lives alone.  He is currently receiving personal care assistance (PCA) services 22 hours per week. A requested increase of PCA services to 50 hours per week. The patient has several medical conditions that can contribute to functional impairment, including osteoarthritis, chronic gout left knee and cervical radiculopathy.  The patient is followed by a rheumatologist.  The most recent visit was done by phone, and did not appear to identify new problems.  At the previous office visit in late 2019 the patient described pain in ankles, knees (reported as better), back pain, and fatigue.  A recent Emergency Room (ER) visit for leg pain was noted.  

In early 2020 the patient denied pain; but the UAS identifies a few symptoms and problems that indicate patient has some difficulty with daily function.  Gait was noted as unsteady (patient has cane and walker for ambulation).  He needs extensive assistance with bathing and lower body dressing which are often affected when a person has pain, stiffness or decreased range of motion of back and/or lower extremities.  He needs assistance with toileting (transfer and use) and has a raised toilet seat which suggests he has difficulty standing up from a low position (also associated with back and lower extremity joint pain).  He has other DME that indicate difficulty with bathroom tasks, including shower chair which is used when a person has difficulty standing, or is unsteady in the tub or shower; and grab bars, used for stability and/or leverage when standing or changing position in shower/tub or for mobility getting on and off toilet. 

Arthritis is a common cause of pain, decreased mobility and functional decline in older people. Symptoms can fluctuate in frequency and severity, and daily functional ability can vary with symptoms. In the rheumatology notes, it is noted the patient has pain in knees, ankles and back.  He has osteoarthritis which could account for his joint and back pain.  He also has chronic gout (left knee).  The patient takes allopurinol (last uric acid was slightly high) and colchicine, and so it appears the patient has had a long history of gout.  Arthritis of the knee can affect many types of daily activities including walking, transferring, dressing, bathing, toileting, and many household related tasks. 

He currently has PCA 4 hours per day, 5 days per week, with 2 additional hours per week that may have been added for outside activities (e.g. shopping, errands).  The patient could benefit from additional hours of assistance with ADLs including walking, transfers and toileting which occur throughout the day. 
Regarding informal caregivers, the patient talks to his daughter daily but it appears she does not provide assistance on a regular basis.  No other informal caregivers are identified in the UAS.  There is no documentation in the UAS or ATSP indicating that he has informal caregiver assistance on the weekends.

Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services.  It does not appear the patient has informal caregivers who can provide assistance with his daily activities on a regular basis.  The personal care services are indicated to provide assistance with IADLs and ADLs including activities that occur throughout the day (walking, toileting).

Personal Care Assistance 50 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for Personal Care Assistance (PCA) 50 hours a week is reversed.  The medical necessity is substantiated.