Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status, pain of the right lower extremity, osteoarthritis of the ankle and foot, chronic pain syndrome, ulcer of the lower extremity, giant cell arteritis, wound of the skin, history of falling, and history of urinary tract infections. 

Treatment: Personal Care Assistance (PCA) 24 hours per day, 7 days per week (Monday through Sunday) live in. 

The insurer denied coverage for PCA 24 hours per day, 7 days per week (Monday through Sunday) live in. 

The denial is overturned. 

The patient has diagnoses including but not limited to altered mental status, pain of the right lower extremity, osteoarthritis of the ankle and foot, chronic pain syndrome, ulcer of the lower extremity, giant cell arteritis, wound of the skin, history of falling, and history of urinary tract infections. 

The patient had an assessment which was requested due to a significant change in status reassessment. The patient lives alone. The patient has minimally impaired cognitive skills. She also has short-term memory and procedural memory difficulties. Her change in decision-making as compared to 90 days ago has declined. The grandson's cousin came from out of state to help the patient temporarily until the 24 hours live in request is determined. Wandering is present but not exhibited in the last three days. Resisting care is present but not exhibited in the last three days. The patient is left alone one to two hours during the day. The patient requires maximal assistance for meal preparation, managing medication, shopping, and transportation. The patient requires extensive assistance with toilet use, toilet transfer, walking, lower body dressing, upper body dressing, personal hygiene, bathing, stairs, and phone use. The patient requires total dependence doing ordinary housework and managing finances. The patient requires limited assistance doing bed mobility. Her activities of daily living (ADL) status as compared to 90 days ago has declined. Her overall self-sufficiency has not changed significantly in the past 90 days. She is frequently incontinent of bladder and infrequently incontinent of bowel. She has had no falls in the last 30 days but fell 31 to 90 days ago. She has had no hospitalizations in the last 90 days, however she has had one emergency room visit. 

The patient has multiple devices to assist her including a shower chair, grab bars, toilet grab bar, walker, cane, wheelchair, compression stockings, and alert system. 

The appeal notes that the daughter was recently hospitalized and is unable to provide necessary care beyond the scope of the approved eight hours. The patient needs help with toilet care, transfers, and ambulation assistance in the overnight hours. 

Personal care assistants (PCA) aid with ADLs and instrumental activities of daily living (IADLs) only. Based on the documentation, the patient's overall self-sufficiency has not changed. However, her social situation has changed due to her daughter, who was an informal helper especially at nighttime, is no longer able to help. She is not able to handle her incontinent supplies alone. The request is for additional hours for toileting given that the patient's daughter is unable to help. Given the above, the plan's recommendations are not appropriate for the level of support needed by this patient. 

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 Assistance (PCA) 24 hours per day, 7 days per week (Monday through Sunday) live in is overturned. Medical Necessity is substantiated.