Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease; Osteoarthritis

Treatment: Personal Care Assistance (PCA) services.

The insurer denied coverage for personal care assistance (PCA), 31 hours per week.

The denial is overturned. 

This male patient has a medical history including Alzheimer's, dizziness, difficulty walking, osteoarthritis, chronic pain, type 2 diabetes mellitus, vertigo, benign prostatic hypertrophy, anemia, hypertension, peripheral artery disease with ulcer, and coronary artery disease. The patient lives alone and is alert and oriented x 2. He receives personal care assistance (PCA) 27 hours/week (9-2 on Monday, Tuesday and Thursday, and 9-3 on Wednesday and Friday). There are no informal supports after the aide leaves. The patient reported daily dizziness, instability while walking, fatigue and need for assistance with getting up from a seated position. He requires assistance with all activities of daily living (ALDs). He requested an increase of PCA services to 31 hours per week, which was denied.

A recent Uniform Assessment System (UAS) indicates patient needs maximal assistance for meal preparation, housekeeping and shopping; and extensive assistance for most other independent activities of daily living (IADLs), except phone use (limited assistance). For ADLs, the patient needs extensive assistance for bathing, lower body dressing, toilet use; limited assistance for most other ADLs except eating, bed mobility (independent, set up help). Although the UAS does not report recent falls, the patient is at high risk for falls. His risk factors include: arthritis, pain lower extremities, frequent dizziness (noted as present with walking and getting into bathtub), unsteady gait, cognitive impairment, advanced age, incontinence. The patient has PCA services only 5 days per week and a concern is the patient's need for extensive assistance with bathing, and reports of feeling dizzy and unsteady going into the bathtub. 

When elderly people fall, there is increased risk of serious injury (e.g. fractures, head trauma), associated with substantial morbidity and increased risk of death. As people age, especially at such an advanced age as this patient, functional reserve decreases. When an acute illness or injury occurs, risk of poor outcome increases and it is less likely the person can return to the prior level of function. A fall prevention plan is needed, which should include assistance for the patient in high risk situations. The UAS reports patient needs extensive (weight-bearing) assistance for bathing, lower body dressing and toilet use. Without assistance for these activities the patient has a greater chance of falls and injury. Elderly people who live alone are at risk for decreased food and fluid intake, and so the patient's nutrition and hydration may be compromised on the days he is alone.

Considering the patient's medical history and functional impairment, it is medically necessary for the patient to have caregiver assistance for IADLs and ADLs 7 days per week. The patient may have periods of improved function, but with the chronic progressive nature of his medical conditions (e.g. arthritis, peripheral neuropathy, cardiovascular disease, cognitive impairment), it is expected that the patient will need assistance with daily activities on a long term basis. Insufficient assistance with daily activities increases the patient's risk of adverse health and safety events which can exacerbate and accelerate further functional decline. The patient has no support from informal caregivers; therefore, personal care services are indicated to provide necessary assistance with IADLs and ADLs.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for Personal Care Assistance (PCA) services at 31 hours per week is substantiated. The insurer's denial should be overturned.