Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis

Treatment personal care aide (PCA) services for a total of 70 hours per week

The insurer denied coverage for personal care aide (PCA) services for a total of 70 hours per week.

The denial is overturned.

This female is reported to have had cognitive and physical decline a few months ago resulting in decreased ability to perform daily activities. The patient lives alone in an apartment and was receiving assistance with daily activities from personal care services (PCS) 16 hours per week. After consultation with her primary care provider (PCP), psychiatrist and other specialists, the son decided to take the patient to a nursing home (NH) where she received rehabilitation services. 

The patient has osteoarthritis. It is noted in the Uniform Assessment System (UAS) that she has limited range of motion (ROM) in upper and lower extremities due to osteoarthritis, and upper and lower extremity joint pain. In the UAS, it was reported that she has difficulty elevating her arms and has shoulder pain due to osteoarthritis. Limitation of shoulder function affects many daily activities, including bathing, dressing, personal hygiene, toilet use and household tasks that require reaching, lifting, carrying. It was noted that she has right hand pain, which can limit tasks requiring manual dexterity. It was also reported that she has difficulty bending and standing for long periods of time, which may be due to arthritis of the spine, and/or lower extremity joints. The UAS indicated patient has difficulty moving to a standing position (transfer activity), also suggesting the effects of osteoarthritis of lumbar spine, knees, or hips. The nursing comments noted that the patient transfers with one person assist with assistive device and holding on to furniture and walls for support. Difficulty with transfers can increase risk of falls.

Urinary incontinence was described as occasional. It was attributed to functional incontinence (inability to reach a toilet in time). A person with impaired mobility (transfers and walking) is at increased risk of functional incontinence, as the time to reach the toilet or commode can be delayed due to slow movement. When the patient's symptoms of joint pain and stiffness are greater, her mobility is slower and may result in greater frequency of incontinence. When the patient has a strong urge to urinate, it is likely that effort is made to move quickly to the bathroom. However, attempt to reach the toilet quickly could result in greater instability with transfer and ambulation, and due to cognitive impairment, there is less attention to safety precautions, which can result in falls.

The patient's son was identified in the UAS as the only informal caregiver. It was noted that he visits the patient daily; but is unable to provide daily care. As per NYS (New York State) regulations for personal care services, assistance from informal caregivers is voluntary. Without informal caregivers who can provide consistent help with daily activities when needed each day, then personal care services are indicated to provide assistance with Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs) when needed throughout the day. The patient will benefit from having caregiver assistance for daily activities from morning until evening when she is most active and in need of more frequent care.

Personal Care Services, 10 hours per day, 7 days per week; total of 70 hours per week are medically necessary. The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient. 

The insurer's denial of coverage for the requested Personal Care Services of 10 hours per day, 7 days per week for a total of 70 hours per week is reversed. Medical necessity is substantiated.