Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Disease.

Treatment: Personal care aide (PCA) Level 2 services: 8 hours per day, 7 days per week for a total of 56 hours per week.

The insurer denied coverage for personal care aide Level 2 services: 8 hours per day, 7 days per week for a total of 56 hours per week

The denial is overturned

The patient is a female that has various medical conditions and functional impairment limiting her daily activities. The patient lives alone. She has a supportive family who provide some informal help with Instrumental Activities of Daily Living. She receives personal care aide services 25 hours per week (3 or 4 hours per day). The patient requested increase of personal care aide services to 56 hours per week, which was denied. An external appeal was requested by her son as designee for the patient.

The functional status report for Instrumental Activities of Daily Living indicates meal preparation, housework, shopping: maximal assistance; managing finances and medications, stairs, transportation: limited assistance; phone use: independent. For Activities of Daily Living, bathing, lower body dressing, walking/locomotion, toilet transfer: extensive assistance; upper body dressing: limited assistance; personal hygiene, toilet use: supervision; eating: setup help; bed mobility: independent. 

The Uniform Assessment System description of the patient's cognition indicates some short term memory loss, oriented to person, place, an time, occasional confusion (calls her children to help re-orient her), occasional problem with decision making for daily activities (noted as only in new situations). No problems were identified with communication (expression and comprehension). She was able to verbalize an emergency plan. She uses the phone independently, and needs limited assistance with medications and finances. There are no other records available that describe patient's cognition. It appears the patient may have some mild cognitive deficits, but it does not appear to be a primary factor in her functional decline with daily activities.

The patient has extensive cardiovascular history, as reported by the physician and in the Uniform Assessment System, including: coronary heart disease with angina, atrial fibrillation, pacemaker, hypertension, peripheral arterial disease. Medications include: amlodipine, clonidine, losartan, metoprolol, isosorbide mononitrate, and eliquis. Other than claudication due to peripheral artery disease, there is no other information regarding the patient's current cardiovascular status. 

The Uniform Assessment System indicates the patient has limited assistance from informal caregivers. As per New York State regulations for personal care services, assistance from informal caregivers is voluntary. Considering the request for increase of personal care services is 56 hours per week, 8 hours per day, it is reasonable to conclude that informal caregivers are unable to provide the necessary help with daily activities during this amount of time each day; which includes the hours of the day when the patient is most active and needs the most frequent assistance (morning through evening). When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide necessary assistance with Activities of Daily Living and Instrumental Activities of Daily Living when needed throughout the day.

Personal Care Aide Level 2: 8 hours per day, 7 days per week; total of 56 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 insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services: 8 hours per day, 7 days per week for a total of 56 hours per week is reversed. Medical necessity is substantiated.