Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End stage renal disease, Chronic pain, Cognitive impairment
Treatment: for Personal Care Assistance (PCA) hours 6 hours per day 5 days per week (Monday through Friday) a total of 30 hours per week
The insurer denied coverage for Personal Care Assistance (PCA) hours 6 hours per day 5 days per week (Monday through Friday) a total of 30 hours per week.
The denial is overturned. 

This is a female patient with an extensive medical history, including recent significant change in treatment; the patient has end stage renal disease (ESRD) and started hemodialysis. The patient has functional impairment and needs assistance with daily activities. The patient has been receiving personal care assistance (PCA) services. The patient was approved for PCA 14 hours per week (allocated over 4 days per week).  The patient (via designee) requested PCA 30 hours per week.

The patient's most recent Uniform Assessment System (UAS) report was done prior to the patient starting hemodialysis treatments. The functional assessment indicated the patient needs maximal assistance for meal preparation, housekeeping tasks and shopping.  For Activities of Daily Living (ADLs), she needs extensive assistance for bathing and lower body dressing, and limited assistance for toileting and upper body dressing.  It was noted that the patient could walk independently with an assistive device, but nursing comments also noted that patient's balance is unsteady at times. For transfers, it was noted that she needs help with transfers, including toilet transfers. 

The patient has several medical conditions and associated symptoms that most likely contribute to physical and cognitive impairment and have a substantial effect on her daily function: chronic pain; impaired hand dexterity; fatigue; vision loss; and cognitive impairment. The patient experienced a significant change in her life when she started dialysis on a regular basis. Dialysis is associated with multiple symptoms that can cause reduced function for daily activities.  The patient's daughter's letters provide a recent description of the patient's functional status (since starting hemodialysis).  The patient's daughter reported increased frequency and/or severity of symptoms affecting the patient's function, including increased fatigue, weakness, lethargy; hand tremors; dizziness; unable to walk long distances; increased frequency of mental confusion. Considering the patient's medical conditions (including recent addition of dialysis), and the various physical and cognitive problems affecting the patient's functional ability for daily activities, it is medically necessary and in the patient's best interest to have caregiver assistance for a more extended period of the day, including dialysis and non-dialysis days. 

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services.  When informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed. The maximum number of hours that can be approved from this review is limited by the number of hours requested; in this case, 30 hours per week.  Allocation of PCA hours should be determined with the patient and her designee to determine the best use of the 30 hours per week.
 
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 PCA hours 6 hours per day 5 days per week (Monday through Friday) a total of 30 hours per week is overturned.  The medical necessity is substantiated.