Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Falls, coronary artery disease, hypertension, diabetes mellitus, sciatica, vertigo, and compression fracture 
Treatment: personal care aide services: 6 hours per day, 7 days per week, for a total of 42 hours per week
The insurer denied coverage for personal care aide services: 6 hours per day, 7 days per week, for a total of 42 hours per week
The denial is overturned

This is a geriatric patient with medical history including chronic falls, coronary artery disease, hypertension, diabetes mellitus, osteoarthritis of multiple sites, sciatica, vertigo, and impaired balance. The patient needs assistance with all daily activities. The patient lives at home with their spouse. The patient's daughter reported that the spouse has health problems and is unable to assist the patient with any daily tasks. One informal helper was identified in the Uniform Assessment System (UAS) but is unable to provide care on a regular basis. The patient was receiving personal care aide (PCA) services 16 hours per week. The patient (via designee) requested an increase of PCA services to 42 hours per week, which was denied; but PCA services were increased to 28 hours per week. An external appeal was requested for PCA services 42 hours per week. The current daily total number of mutual PCA hours for the patient is 4 hours per day and 4.5 hours per day for the spouse.

Comparing the most recent UAS to the previous UAS demonstrated there was a decline in the patient's ability to complete activities of daily living (ADLs) from extensive assistance to maximal assistance. The daughter's letter reports the patient's condition has deteriorated over the last 3 months; the patient has become homebound and completely dependent on the PCA for all ADLs. Physician evaluations are now done as home visits. The physician's letter reported recent functional decline; dependence on caregivers for ADLs and instrumental activities of daily living (IADLs) and increase of falls (3 in the past month).

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. Considering the information provided for review, it is medically necessary, and in the patient's best interest to have assistance for all IADLs and ADLs, including activities that occur at unplanned and/or recurring times throughout the day, including: mobility (transfers, walking, wheelchair); toileting/incontinence care; meals; medications; morning and evening ADLs (dressing, personal hygiene). These care needs must be considered when determining personal care service hours.

The patient's medical history and functional status support the need for assistance with daily activities beyond the current shared 8.5 hours per day. The current schedule does not provide care during evening/night hours. The informal helper does not live close to the patient and is unable to provide care on a regular basis. As per New York State regulations for personal care services, assistance from informal caregivers is voluntary. When informal helpers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed throughout the day. Increase of the patient's individual PCA hours from 28 to 42 hours per week will increase daily PCA services by 2 hours per day. Increase of PCA hours can help provide safe, effective toileting/incontinence care, and assistance with pain management for a longer period of time each day; help maintain adequate food and fluid intake; and help decrease occurrence of falls. 

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 an increase in personal care aide services: 6 hours per day, 7 days per week, for a total of 42 hours per week is substantiated.