Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, osteoarthritis, and lumbar radiculopathy

Treatment: Personal care aide (PCA) level 2: 7.5 hours per day- 6 days per week- for a total of 45 hours per week

The insurer denied coverage for personal care aide (PCA) level 2: 7.5 hours per day- 6 days per week- for a total of 45 hours per week

The denial is overturned

This patient has experienced increasing functional impairment associated with progression of her medical conditions. The patient lives alone. She needs assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She receives personal care aide (PCA) services 5.5 hours per day, 6 days per week, total of 33 hours per week. The patient advocate's letter indicated the patient has informal help. The patient reported she has increased difficulty with daily activities. She requested increase of PCA services to 7.5 hours per week, 6 days per week, total of 45 hours per week. 

Based on the records, it appears the patient's functional decline is mostly due to the effects of heart failure, osteoarthritis, and lumbar radiculopathy. 

The uniform assessment system (UAS) notes the patient has poor endurance and fatigue to the extent that she is unable to finish daily activities. She has dyspnea with normal activities, and intermittent peripheral edema. She reports that she needs more frequent rest to complete ADLs due to heart failure. The patient's physician reported the patient lost weight over previous months and needs a reminder to eat dinner. 

As per the neurologist, due to her lumbosacral radiculopathy, she cannot stand for more than 10 minutes, which limits her ability for many household tasks. It is reported that the patient has an unsteady gait and difficulty moving to a standing position. It is likely that back and knee pain contributes to patient's impaired mobility. 

The UAS clearly indicates the patient needs assistance with toileting. The need to use the toilet and episodes of incontinence occur at various unplanned times throughout the day. There is no clinical basis for providing assistance for toileting 5.5 hours per day, and no assistance for the rest of the day. The patient needs assistance for toileting related tasks beyond the current allocation of PCA hours.

MLTC (Managed Long Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. When the patient needs assistance with toileting, transfers, walking, food/fluids, this is not stand-alone safety supervision. This is assistance the patient needs for proper and safe completion of daily activities. The patient has chronic medical conditions that adversely affect her ability to perform daily activities. Her functional status does not improve when the PCA shift ends each day. The patient needs assistance for multiple ADLs throughout the day beyond the current allocation of PCA hours. These care needs must be considered in the determination of the patient's personal care service hours.

The records provided indicate the patient has substantial physical impairment due to various medical conditions and associated symptoms. The patient's care needs cannot be adequately met with PCA 5.5 hours per day. Increase of services is medically necessary to help prevent adverse health and safety events, skin damage due to inadequate hygiene with toileting/incontinence, nutritional decline, dehydration, complications of swallowing problem.

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 personal care aide (PCA) level 2: 7.5 hours per day- 6 days per week- for a total of 45 hours per week is overturned. Medical Necessity is substantiated.