Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease (CAD), hypertension, hyperlipidemia, and asthma. 
Treatment: PCA (Personal Care Aide) level 2: 8 hours per day- 7 days per week- for a total of 56 hours per week. 

The insurer denied coverage for PCA level 2: 8 hours per day- 7 days per week- for a total of 56 hours per week. 

The denial is overturned. 

This patient has functional decline associated with her medical conditions and needs assistance and supervision with daily activities. The patient lives alone. She has been receiving Personal Care Aide (PCA) services 4 hours per day, 7 days per week; total of 28 hours per week. The most recent UAS (Uniform Assessment System) provided for review was done. The functional status report indicated for instrumental activities of daily living (IADLs) the patient was totally dependent for managing finances; she needed maximal assistance for meal preparation, ordinary housework, shopping, managing medications; extensive assistance for phone use; limited assistance for transportation; supervision for stairs. For activities of daily living (ADLs), the patient needed supervision for bathing, personal hygiene, dressing upper/lower body, walking, locomotion, toilet use; independent for bed mobility, eating, transfer toilet. 

There are multiple risks associated with poor ability to perform toileting related tasks, especially for a person with dementia, e.g., falls in the bathroom; inadequate cleaning/hygiene after toileting and incontinence which can lead to skin damage (e.g., dermatitis, fungal infection); urine and fecal waste on the floor which can cause slip and fall accidents; unsanitary conditions in the home. Based on the patient's cognitive impairment as described in the UAS, and progression of symptoms as reported by the daughter recently, it is apparent the patient needs supervision and/or assistance for toileting related tasks to ensure proper performance of the tasks and prevent adverse health and safety events. 

The patient has significant cognitive impairment causing difficulty with performance of most daily activities due to confusion, impaired memory, poor judgment, and poor safety awareness. Based on information in the UAS, it appears the patient also has symptoms causing physical functional impairment, including pain, stiffness, weakness (limited medical information is available to identify the cause of these problems). Due to cognitive and physical impairment, the patient is at increased risk for falls and household accidents; skin damage due to inadequate incontinence care; malnutrition and dehydration due to lack of assistance and supervision at all meals. 

Assistance/supervision with daily activities can help provide safe, effective completion of daily activities. 

With consideration of the information provided for review, and the risk of harm due to insufficient assistance for daily activities, it is medically necessary and, in the patient's best interest to have caregiver assistance for a more extended period of the day. The daughter requested 24-hour care in the external appeal letter. However, the insurer's final denial letter indicated request was for PCA 56 hours per week (which was confirmed through communication between the agents representative and the insurer). The UAS identified 2 informal caregivers who provided ADL and IADL care 15 hours over 3 days. It was also noted that an aide was being paid for services 8 hours per day, 7 days 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 personal care aide (PCA) level 2: 8 hours per day- 7 days per week- for a total of 56 hours per week is overturned. Medical Necessity is substantiated.