Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, essential primary hypertension, localized edema, chronic pain, osteoarthritis. 
Treatment: Personal care aide (PCA) Level II services of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The insurer denied coverage for PCA) Level II services of 12 hours per day, 7 days per week for a total of 84 hours per week. 

The denial is overturned. 

This female has decreased ability to perform daily activities due to various medical conditions. She lives alone and receives some assistance from her children, but primarily relies on personal care services for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient receives personal care aide (PCA) services 42 hours per week; 6 hours per day, 7 days per week. The patient (via designee) requested increase in services to 84 hours per week, which was denied. 

The most recent Uniform Assessment System (UAS) provided for review was done. The functional status report indicates the patient needs maximal assistance or total dependence for most IADLs, except phone use (extensive assistance) and managing medications and finances (limited assistance). The patient needs extensive assistance for most ADLs, except bed mobility (limited assistance) and eating (setup help). 

The patient has frequent urinary incontinence, and it is likely to occur more often when she is alone due to her slow impaired mobility which may prevent her from reaching the toilet in time (functional incontinence). It was noted in the UAS that a caregiver needs to change the soiled pullup. Considering the UAS reports the patient needs extensive assistance for toileting and lower body dressing, it is reasonable to expect that the patient currently needs at least the same level of assistance for incontinence care, or possibly more. 

Managed Long Term Care (MLTC) policy 16.07 states that managed long term care plans must assure that the plan of care can meet any of the patient's unscheduled or recurring daytime or nighttime needs for assistance. Therefore, the patient's need for assistance with transfers, walking, toileting that occurs at various unscheduled times during the day must be considered in the determination of the patient's personal care service hours.

Considering the patient's medical history and functional status as noted in the available records, it is apparent that the patient needs substantial assistance for most ADLs and IADLs. Therefore, it is medically necessary, and in the patient's best interest, to have a caregiver present throughout the day to assist with daily activities. The patient needs assistance for IADLs and ADLs that occur at various scheduled and unscheduled times throughout the day. This includes routine household tasks, and preparation/service of all 3 meals; routine morning and evening ADLs (e.g., bathing, dressing, personal hygiene); unscheduled/recurring activities, including toileting related tasks/incontinence care; out-of-bed mobility (transfers, walking). Without adequate assistance, the patient is at risk for adverse health and safety events, e.g., skin damage due to incontinence; falls/injury; nutritional decline, dehydration.

As per the UAS, the patient has two informal caregivers, but it appears the time provided by the caregivers is limited (5 hours over previous 3 days). Considering the request for increase of PCA services is for 84 hours per week, 12 hours per day, it is reasonable to conclude that there are no informal caregivers who can provide care during that period of time each day. Assistance from informal caregivers is voluntary as per NYS (new York State) 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 for daily activities, including ADLs that occur at unscheduled and recurring times throughout the day.

The request for 84 hours per week - Personal Care Aide Level II PCA Level II Basic - 15 minutes is medically necessary. 

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 Personal Care Aide (PCA) Level II services of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical necessity is substantiated.