Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis and unsteady gait.

Treatment: Personal Care Aide (PCA) Level 2 Services of Live-In Per Diem at 24 hours per day, 7 days per week. 

The insurer denied coverage for PCA Level 2 Services of Live-In Per Diem at 24 hours per day, 7 days per week. 

The denial is overturned. 

This is a female patient with a past medical history of pressure ulcers, atrial fibrillation, iron deficiency anemia, urinary retention, severe osteoarthritis with multiple joint replacements, cervical spine stenosis, chronic constipation, decreased mobility requiring a walker and 1 person assistance, status post right shoulder dislocation and subclavian artery dissection repair. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her daughter were present on the call. The patient lives alone in a 1-bedroom apartment with elevator access. She was residing at a Rehabilitation Facility prior to the UAS-NY completion for services following a hospitalization for an elective right upper extremity angiogram with subclavian angioplasty and stent. The patient requires assistance with activities of daily living and instrumental activities of daily living due to her osteoarthritis, pain related to osteoarthritis and an unsteady gait. She has right arm weakness.  

Needs are: 

-	Total dependence for ordinary housework and stairs;
-	Maximal assistance for meal preparation, managing medications and shopping;
-	Extensive Assistance for transportation, bathing, personal hygiene, dressing her upper and lower body, walking  [uses assistive device (AD)], locomotion, toilet transfer and toilet use;
-	Independence for bed mobility.
-	Cognition: There is mild impairment. 
-	Continence: There is frequent bladder incontinence and infrequent bowel incontinence. She uses diapers for her incontinence. 

In comparison of a previous Uniform Assessment System (UAS) report to the more recent UAS-NY, the patient's level of assistance needed, especially with upper body (UB) dressing, walking, locomotion and personal hygiene has increased. 

An increase to Personal Care Aide (PCA) level 2 services of live-in per diem at 24 hours per day, 7 days per week was requested.

The patient has multiple functional limitations. They have progressed, especially in UB dressing right arm atrophy, personal hygiene and locomotion. The patient is incontinent of bowel and bladder (B&B) and has a history of pressures sores. Her ability to move in bed appears to be good, but she would have great trouble with toileting, either handling a soiled diaper or going to the bathroom. 

The provision of diapers is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" in https://www.ncbi.nlm.nih.gov/books6430/ updated November 15, 2018 changing diapers regularly is necessary. 

The patient has both constant and unscheduled needs, and is at high risk for pressure sores without proper performance of toileting. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The reviewer disagrees with the plan. They did not take into account the extent of the patient's functional limitations.	

The insurer's denial of coverage for the requested PCA Level 2 Services of Live-In Per Diem at 24 hours per day, 7 days per week is overturned. Medical necessity is substantiated.