Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, osteoporosis, dizziness, major depressive disorder, and pain
Treatment: Increase in personal care assistance (PCA) service to 40 hours per week
The insurer denied the increase in personal care assistance (PCA) service to 40 hours per week
The denial is overturned.

This elderly patient needs assistance with most daily activities due to functional decline associated with several medical conditions. The patient lives with family. The patient has been receiving personal care assistance (PCA) services 25 hours per week (5 hours per day, 5 days per week). 

The most recent UAS (Uniform Assessment System) provided was reviewed. Functional status report for IADLs (instrumental activities of daily living) indicates the patient needed maximal assistance for meal preparation, ordinary housework, shopping; extensive assistance for managing finances and medications, transportation, stairs; and supervision for phone use. For ADLs (activities of daily living) the patient needed extensive assistance for bathing, dressing upper/lower body; limited assistance for personal hygiene, walking, locomotion, transferring to the toilet, toilet use; set up help for bed mobility, and eating.

The patient lives with family. The UAS noted that the patient has 2 daughters, and each works from morning to 5pm or 6pm. The patient is currently receiving PCA services 25 hours per week, (5 hours per day, 5 days per week). The daughter (patient designee) requested an increase of PCA services to 40 hours per week. Considering the patient's recent change in health status (lung carcinoid) associated with declining physical function, and possibly declining cognitive function, this is a reasonable and realistic request. The patient lives with her family, and so it appears the family can provide informal help when needed during the other hours of the week. Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. During periods of time each day when informal caregivers are unable to provide necessary care on a consistent basis, then personal care services are indicated to provide necessary assistance for daily activities when needed each day. 

With consideration of all the issues impacting the patient's health and safety as discussed in this review, it is medically necessary, and in the patient's best interest to have caregiver assistance for all daily activities throughout the day. In
addition to her chronic medical conditions, the patient is experiencing a new stressful situation with the diagnosis of lung carcinoid tumor. The patient needed help with most daily activities at the time of the most recent UAS, and her care needs appear to have increased since then due to effects of the lung disease and treatment. Her condition may improve at some point; but at the present time, based on the most recent available information, the patient needs assistance for all daily activities throughout the day to help prevent adverse health and safety events, e.g., skin damage due to inadequate toileting and incontinence care; infection, weight loss/malnutrition, dehydration, falls and injuries. 

MLTC (Managed Long-Term Care) policy 16.07 states that plans must assure that the plan of care can meet any unscheduled or recurring daytime or nighttime need for assistance. The patient needs assistance to ensure safe, effective completion of all daily activities that occur throughout the day, including all routine ADLs and IADLs; and activities that occur at unscheduled and/or recurring times of the day (e.g., toileting and incontinence care, transfers, walking, meals). These care needs must be considered in the determination of the patient's personal care service hours.

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 increase in personal care assistance (PCA) service to 40 hours per week services is substantiated.