Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional Impairment

Treatment: personal care aide (PCA) services 2-12 hour split shifts, 7 days a week

The insurer denied coverage for personal care aide (PCA) services 2-12 hour split shifts, 7 days a week

The denial is overturned

 
This elderly patient has extensive medical history associated with functional impairment that affects her ability to perform daily activities. The patient lives with her ex-husband. He is identified as an informal helper in the Uniform Assessment System (UAS), but the UAS and patient's daughter indicate he is unable to provide the level of care the patient needs due to his own health problems. Another informal helper assists with some instrumental activities of daily living (IADLs). The patient primarily relies on personal care aide (PCA) services for assistance with ADLs and IADLs. The patient was receiving PCA 84 hours per week (12 hours per day). The patient (via designee) requested increase of PCA services to 2-12 hour split shifts per day, 7 days per week, which was denied. On appeal, the denial for split shift was upheld; but live-in services were approved. 

The most recent UAS provided was reviewed. Functional status report indicates patient was totally dependent for meal preparation, ordinary housework, shopping, stairs, transportation; she needed maximal assistance for managing finances; extensive assistance for managing medications, phone use. For ADLs, the patient was totally dependent for bathing; she needed maximal assistance for dressing lower body, walking, locomotion, transfer toilet, toilet use; extensive assistance for personal hygiene, dressing upper body, bed mobility; limited assistance for eating.

The patient has chronic pain. The records indicate she has osteoarthritis. The full extent of joint involvement is not noted, but the records indicate the patient's knees have been substantially affected by arthritis. The UAS reports patient had left knee replacement; reason for procedure is not noted, but severe knee osteoarthritis is a common cause of knee replacement. The records indicate patient has frequent pain in her right knee, pain scale at rest 3/10; with movement 5/10. The daughter reported patient has continuous right knee pain restricting her mobility. The UAS reports lumbar spondylosis with low back pain. The UAS also reports leg pain (cause is not noted). The effects of pain in the lower extremities and lower back can contribute to difficulty with all mobility including walking, transfers (as per UAS, patient has difficulty standing up from sitting position), and stairs.

Considering the patient's medical history and functional status as described in the available records, it is medical necessary for the patient to have 24 hour personal care services to provide assistance with all daily activities, including IADLs (housekeeping, meal preparation/service, medications); routine ADLs (bathing, personal hygiene, dressing, eating); plus ADLs that occur at unscheduled and/or recurring times of the day and night (walking, transfers, toileting/incontinence care, bed mobility/repositioning).  Personal care assistance 24 hours per day is necessary to help prevent adverse medical events (such as incontinence associated skin damage, pressure ulcers, falls/injuries); and help with pain relief.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care aide (PCA) services 2-12 hour split shifts, 7 days a week is substantiated.