Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional impairment

Treatment: Patient Care Aide services - level 2, 70 hours/week, 10 hours times 7 days

The insurer denied coverage for Patient Care Aide services - level 2, 70 hours/week, 10 hours times 7 days

The denial is overturned

This elderly female has functional impairment which limits her ability to perform routine daily activities. The patient lives alone. No informal helpers are identified in the UAS (Uniform Assessment System). The patient receives personal care aide (PCA) services 56 hours per week (8 hours per day, 7 days per week). 

The functional status report for instrumental activities of daily living (IADLs) indicates patient needed maximal assistance for meal preparation, ordinary housework, shopping, transportation, stairs; limited assistance for managing finances; supervision for managing medications; setup help for phone use. For activities of daily living (ADLs), the UAS noted walking did not occur during entire period; patient needed extensive assistance for bathing, dressing upper/lower body, toilet use; limited assistance for personal hygiene, transfer toilet, locomotion (wheelchair), bed mobility; setup help for eating.

Decision making for tasks of daily life is described as modified independence - some difficulty in new situations. The patient was oriented to person, time and place; she had short-term memory problem. It was noted that she is self-directing. Communication for expression and comprehension was reported as clear. Assessment of the patient's cognition identified short term memory impairment, but no other significant problems were noted. 

The patient has multiple medical conditions that are probable contributing factors to her functional decline: Chronic pain, Cardiovascular disease, Chronic kidney disease.

The UAS indicates the patient needs limited assistance for toilet transfer. She has frequent urinary incontinence. Community friend reported that the patient wears diapers and is unable to change diapers unassisted. One possible cause of the patient's incontinence is delay in reaching a toilet or commode in time due to difficulty with mobility (i.e., functional incontinence). The UAS reported infrequent bowel incontinence. 

The patient has substantial mobility problems that affect various aspects of her daily life. The UAS reported the patient was not walking and uses wheelchair (with assistance) for mobility.  She needs assistance with all transfers. There is a history of falls. 

UAS indicates the patient needs assistance for evening activities, including meal preparation/service, dressing, personal hygiene, possibly evening bathing (especially when she has frequent incontinence during the day). She needs help with transfer between wheelchair and bed. 

Considering the patient's medical history and functional impairments, caregiver assistance is medically necessary at various times throughout the day to help maintain patient's health and safety. 

Per the UAS, the patient has no informal helpers. When informal caregivers are unavailable to provide care on a regular basis, then personal care services are indicated to provide necessary assistance as needed; including those that occur at unscheduled and recurring times through the day. The patient will benefit from the increase of Personal Care Aide services (to 10 hours per day) which can extend until later in the evening.  

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 Patient Care Aide services - level 2, 70 hours/week, 10 hours times 7 days is substantiated.