Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary heart disease, diabetes, heart failure, dementia, benign prostatic hypertrophy (BPH), hypertension, hypothyroidism, hypercholesterolemia, glaucoma
Treatment: Personal Care Aide (PCA) level 2: 10 hours per day - 7 days per week - a total of 70 hours per week
The insurer denied coverage for PCA level 2: 10 hours per day - 7 days per week - a total of 70 hours per week.
The denial is overturned.

This is an elderly male with extensive medical history associated with significant functional impairment who needs assistance with all daily activities.  He lives alone. No informal caregivers are identified in the Uniform Assessment (UAS). He has family who are supportive but do not live locally. The patient depends on PCA services for assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). He was receiving PCA services 56 hours per week (8 hours per day). 

The most recent UAS provided for review describes the patient's functional status for IADLs as totally dependent for meal preparation, ordinary housework, shopping; he need maximal assistance for managing finances and medications, transportation, phone use, stairs. The patient needs maximal assistance for all ADLs; except for toilet use, he is totally dependent. 

Functional decline in the elderly is usually the result of cumulative and interactive effects of multiple medical conditions resulting in physical and/or cognitive impairment. Other factors include economic and social circumstances, (e.g., caregiver support). The patient's medical history includes several conditions that are probable contributing factors to his functional decline.

The patient is totally dependent for meal preparation and he needs maximal assistance for eating. Current PCA services (9 hours per day) may be sufficient for all 3 meals if the patient has appetite for dinner before the aide leaves. Older people with chronic health problems may have variable eating patterns and may not always conform to a standard meal schedule. If the patient is not eating dinner sufficiently before the aide leaves each day, he probably does not eat again until the aide returns the next day, as he is unable to feed himself when he is alone. Extended hours into the evening may be needed to ensure adequate intake. 

Managed Long Term Care (MLTC) 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. Therefore, all the patient's care needs throughout the day must be considered in the determination of the patient's personal care service hours.

The records provided for review describe the patient as severely functionally impaired due to physical and cognitive impairment. He needs substantial assistance with all ADLs and IADLs. The information provided for review supports the patient's need for increase of PCA services, as requested, to 70 hours per week, 10 hours per day. There is concern about the remaining 14 hours of the day, as it appears the patient has personal care needs through the evening and night. It is not known whether the family has arranged for assistance during non-PCA hours.

The maximal number of hours that can be approved from this review is limited by the hours requested, as documented in the insurer's final adverse determination denial notice; in this case, 70 hours per week. Recommendation is given to approve Personal Care Aide services Level 2: 10 hours per day, 7 days per week; total of 70 hours per week.

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 the personal care aide (PCA) level 2: 10 hours per day - 7 days per week - a total of 70 hours per week is overturned. Medical Necessity is substantiated.