Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neuropathy. 
Treatment: Personal Care Aide (PCA) level 2 services of 9 hours per day, 7 days per week for a total of 63 hours per week. 

The insurer denied coverage for personal care aide (PCA) level 2 services of 9 hours per day, 7 days per week for a total of 63 hours per week. 

The denial is overturned. 

This female with various medical conditions contributing to functional impairment and needs substantial assistance with most daily activities.  The patient lives alone.  She has had multiple falls recently.  She has some informal support from family, which is noted in Uniform Assessment System (UAS) as assistance with instrumental activities of daily living (IADLs).  The patient has been receiving personal care aide (PCA) services 5.5 hours per day, 7 days per week.  The patient requested increase of PCA services to 9 hours per day which was denied. 

The patient has vestibulopathy with impaired balance, unsteady gait and high risk for falls.  The patient is at high risk for falls, with recent h/o of increasing frequency of falls. This is an alert that the patient's fall prevention plan needs re-evaluation.  Few, if any, interventions can prevent all falls but the purpose of fall assessment is to identify risk, and when necessary, develop a plan to decrease the occurrence of falls.   When a person has poor balance and gait impairment, caregiver assistance can provide stability with ambulation and transfers, and provide safety cues (e.g. avoidance of obstacle on the floor).  These interventions can be the difference between falling and safe mobility. It is reasonable to expect that it is less likely the patient will fall when she has a caregiver to assist with ambulation, and transfers (on/off chair, bed, toilet, commode). 

Walking, transfers, toileting/incontinence occur at multiple and unscheduled times of the day; and so the patient needs a caregiver present throughout the day when needed for mobility and toileting. This is not stand-alone safety supervision.  Providing assistance and cues for safety when needed during ADLs is part of the scope of practice for personal care aides.  MLTC policy 16.07 states that managed long term care plans must assure that the plan of care can meet any of the patient's unscheduled or recurring daytime or nighttime needs for assistance.  Therefore, the patient's need for assistance with transfers, walking, toileting, incontinence that occurs at various times during the day must be considered in the determination of the patient's personal care service hours. 
  
The patient needs assistance for daily activities from morning until she goes to bed at night. There are still some concerns for the patient's health and safety during the hours the aide will not be present.  The current PCA hours are 4pm-9:30pm, indicating the patient wants assistance into the evening when she goes to bed.  The additional 3.5 hours per day will help, but will still not provide assistance from the time she gets up in the morning until she goes to bed at night. There is no available information of the patient's nighttime care needs; e.g. toileting/ incontinence care; transfer, ambulation (if patient tries to get up from bed at night).  It is not known whether family is providing any additional services. 
 
The maximum amount of PCA hours that can be approved from this review is limited by the request for services as stated in the final adverse determination denial notice; in this case, PCA 63 hours per week. 

Personal Care Aide Level 2: 9 hours per day, 7 days per week; total of 63 hours per week are 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 of 9 hours per day, 7 days per week for a total of 63 hours per week is reversed. Medical necessity is substantiated.