Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease, Osteoporosis 
Treatment: Personal Care Aide (PCA) Level 2 services, 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split-shift) - total of 168 hours per week 

The insurer denied the Personal Care Aide (PCA) Level 2 services, 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split-shift) - total of 168 hours per week. 

The denial was overturned. 

This is a male patient with a history of coronary artery disease (CAD), status post (s/p) myocardial infarction (MI), s/p coronary artery bypass graft (CABG), s/p ablation atrial flutter, prostate cancer, history of falls, s/p fracture left rib, osteoporosis, venous insufficiency. It was reported that he was hospitalized in due to COVID-19 he had course of short term rehab with some improvement, and was discharged home. The patient had been receiving personal care aide (PCA) services 56 hours per week prior to hospitalization. The patient lives with his sister and family is involved in his care.  
Functional decline in the elderly is often the result of the cumulative and interactive effects of multiple chronic medical conditions.  An acute illness will often result in further functional decline. If the acute event (e.g. infection) is self-limiting and resolves, some function may be restored after a period of recovery and possibly rehabilitation.  However, the extent and maintenance of improvement is variable.  Records from the rehab facility indicated the patient demonstrated functional improvement with daily activities; but at the time it was reported that the patient needed extensive assistance with most ADLs at home.  

The patient needs maximal assistance or total dependence for all IADLs, except phone use (limited assistance).  For ADLs, the patient needs extensive (weight-bearing) assistance for all ADLs; except bed mobility and eating (limited assistance).  The patient has substantial physical limitations from various medical conditions limiting his ability to perform daily activities.  The patient also has some cognitive impairment, noted as short term and procedural memory loss, and some impairment with decision making for daily tasks.  When a person has cognitive decline, some loss of functional ability is expected.  Decline in ability with IADLs usually precedes loss of ADL skills, as IADLs generally require a higher level of cognitive function. It is likely that the patient's cognitive deficits contribute at least partly to his need for assistance with some IADLs.  It is less clear whether the patient's cognitive status has an effect on the patient's ability for ADLs at this time.  Physical limitations are probably the primary cause of the patient's need for ADL assistance, as described in some of the nursing comments in the UAS.  

The patient has several medical conditions that most likely contribute to these symptoms and functional impairments.  He has osteoarthritis affecting multiple joints (based on UAS history). Arthritis of the spine and lower extremity joints can cause substantial impairment with mobility around his home.  The patient has unsteady gait and needs extensive assistance with walking and transfers.  Difficulty bending affects dressing, bathing and various household related tasks. Decreased hand dexterity affects ability to perform most fine motor tasks (dressing, personal hygiene, eating).  Pain and limited range of motion of the shoulder limits use of arms for activities such as dressing, bathing, toileting.  

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

Based on the above, the medical necessity for Personal Care Aide (PCA) Level 2 services, 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split-shift) - total of 168 hours per week is substantiated.  The insurer's denial is overturned.