Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression, urinary tract infection, essential hypertension, gastroesophageal reflux disease, hypothyroidism, legally blind, osteoarthritis, ulcerative colitis, urinary incontinence, and vitamin deficiency.

Treatment Personal Care Aide (PCA) level 2 services of 16 hours per day, 5 days per week; 12 hours per day, 2 days per week; 12 hours per day, 2 days per week for a total of 128 hours per week.

The insurer denied coverage for PCA level 2 services of 16 hours per day, 5 days per week; 12 hours per day, 2 days per week; 12 hours per day, 2 days per week for a total of 128 hours per week.

The denial is overturned.

The patient is a female with a past medical history of depression, urinary tract infection, essential hypertension, gastroesophageal reflux disease, hypothyroidism, legally blind, osteoarthritis, ulcerative colitis, urinary incontinence, and vitamin deficiency. The most recent Uniform Assessment System (UAS) provided for review was done. The functional status report indicates the patient is totally dependent or needs maximal assistance for all instrumental activity of daily living (IADLs). She needs maximal assistance for most activity of daily living (ADLs); except locomotion: total dependence; bed mobility, eating: extensive assistance. The most recent physical therapy (PT) and occupational therapy (OT) notes from the skilled nursing facility (SNF) provided for review indicated the following: ambulation 15 feet max assist; transfers max assist; grooming/hygiene mod assist; upper body dressing mod assist; lower body dressing max assist; toileting max assist. Patient was discharged home. It is not known if any further improvement occurred between.

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple chronic medical conditions resulting in physical and/or cognitive impairment. 
Cognitive impairment is associated with decline in ability to perform daily activities. The patient's physical impairments are probably the primary cause of her inability to perform household related tasks; but it is possible that cognitive impairment is a contributing factor to the patient's loss of ability to perform IADLs such as food preparation, which relies on procedural memory (noted in UAS as impaired). The patient's physical impairments are probably the primary cause of her limited ability for most ADLs. 

The patient has several other medical conditions that most likely adversely affect her ability to perform daily activities such as arthritis, vision loss, sever hearing loss.

The amount of services that can be approved from this review is limited by the amount requested as noted in the insurer's final adverse determination letter; in this case PCA 16 hours per day x 5 days; PCA two 12 hour shifts per day x 2 days. The records provide for review do not include a plan for the 8 non-PCA hours per day for the 5 days per week when the patient will receive 16 hours of PCA services per day. The patient's care needs are the same every day; and so, considering the daughters are requesting PCA 24 hour continuous care 2 days per week, and only 16 hours per day 5 days per week, it is likely that the family has a plan for the other 8 hours of the day when the patient receives PCA services 16 hours per day.

Personal Care Aide Level 2: 16 hours per day, 5 days per week; 12 hours per day, 2 days per week; 12 hours per day, 2 days per week - total of 128 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 insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 16 hours per day, 5 days per week; 12 hours per day, 2 days per week; 12 hours per day, 2 days per week for a total of 128 hours per week is reversed. Medical necessity is substantiated.