Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease; Osteoarthritis
Treatment: Personal Care Aide (PCA) services
The insurer denied coverage for Personal Care Aide (PCA) services Level 2 services: 8 hours per day - 5 days per week - for a total of 40 hours per week.
The denial is overturned.

This male patient has a medical history of coronary artery disease, diabetes mellitus, Parkinson's disease, atherosclerotic heart disease, hypertension, gastro-esophageal reflux disease, long term use of anticoagulants, other seizures, transient ischemic attack, cerebral infarction, osteoarthritis, and urinary incontinence. He lives in an assisted living facility (ALF). Considering the patient's medical history and recent functional decline, it is medically necessary for the patient to have caregiver assistance for activities of daily living (ADLs) to ensure adequate and safe completion of all daily activities and help prevent adverse consequences due to his limited mobility. The need for assistance with wheelchair mobility, transfers and toileting care occur at various and mostly unscheduled times throughout the day. It does not appear possible that the patient can have adequate care with ADLs throughout the day with assistance for only 3 hours per day. It is also not clear why the patient has personal care assistant (PCA) services only 5 days per week. ADLs occur daily; and so the patient needs assistance daily. The Client Task Sheet noted that there were PCA hours deducted due to senior living facility arrangement; however, no details of this arrangement were noted. It is possible the ALF staff provides some assistance with ADLs. However, the patient's personal care needs have increased since the uniform assessment system (UAS), and it cannot be assumed that the ALF staff is providing all the care the patient needs throughout the day when  the PCA is not present; and all day for 2 days per week. The records provided for review do not identify informal caregivers who are available to provide assistance to the patient for extended periods of time on a daily basis. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. The patient's brother requested PCA 40 hours per week. It is reasonable to conclude that there is no satisfactory plan to provide necessary ADL assistance from informal caregivers or the ALF staff for at least 40 hours per week. Without assistance from informal caregivers on a consistent basis, and with no plan of care from the ALF provided for review describing ADL services, then personal care services are indicated to provide assistance with daily activities when needed throughout the day. 

With request for PCA 40 hours per week, it remains unclear how the patient can have all his ADL needs properly managed each day; including morning ADLs, daytime mobility and toileting/incontinence care, and evening ADLs.  Nighttime activity and the need for ADL assistance at night also needs to be assessed. The maximum number of PCA hours that can be approved from this review is limited by the number of hours requested; i.e. 40 hours per week. These hours can be allocated any way that can best serve the patient's current needs.  

Personal Care Aide Level 2 services: 40 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for Personal Care Aide (PCA) Level 2 services: for a total of 40 hours per week is overturned. The medical necessity is substantiated.