Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus type II, hypertension, coronary artery disease, hypothyroidism
Treatment: Personal care aide (PCA) level 2 services of 6 hours per day, 7 days per week, for a total of 42 hours per week
The insurer denied coverage for PCA level 2 services of 6 hours per day, 7 days per week, for a total of 42 hours per week.
The denial is overturned.

This patient is a female with an extensive medical history associated with functional impairment and needs assistance or supervision with various daily activities. She has diabetes mellitus type II, hypertension, coronary artery disease, hypothyroidism, hypercholesterolemia, B12 deficiency, thyroid cancer status post (s/p) surgery, breast cancer s/p surgery and chemotherapy, and thrombocytopenia. The patient has pain in her lower back, neck and shoulders. She cannot sit or stand for prolonged periods of time or walk long distances. She also has depression, anxiety and cognitive impairment. She forgets to take her medication and pay bills. The patient needs more assistance with activities of daily living (ADLs); 6 hours per day, 7 days per week. She has been receiving personal care aide (PCA) services 4 hours per day, 4 days per week, for a total of 16 hours per week. The patient lives with her husband. The Uniform Assessment System (UAS) indicates the husband provides some informal care to his wife, but he also receives PCA services (mutual case). No other informal caregivers are identified. Patient requested (via designee) increase of PCA hours to 6 hours per day, 7 days per week, for a total of 42 hours per week, which was denied. 

The patient needs assistance with incontinence care, including cleaning and changing of incontinence product. The cause of the patient's incontinence is not reported, but one possible cause may be due to delay in reaching the toilet in time due to slow, unsteady ambulation (i.e. functional incontinence). This can also increase risk of falls, as she may attempt to move quickly to reach the toilet; with unsteady gait and less attention to safety precautions, she may fall. With assistance to walk to the bathroom, she may arrive more quickly and safely. Regarding ambulation, the patient has an unsteady gait, which is probably due to combined effects of knee pain and stiffness from arthritis, gait problems associated with neuropathy, and intermittent dizziness. The patient has a history of falls.
 
The UAS reports the patient needs only supervision for walking. Considering the patient's diagnoses and symptoms, it is likely the patient can benefit from at least limited assistance for stability with transfers and walking and at times she may need some weight-bearing assistance (e.g. when knee pain is worse or her legs feel weak).  

The UAS indicates the patient's husband was her only informal caregiver at that time. Considering the husband has PCA services for his own care needs, it is likely that his ability to provide assistance to his wife is limited. Current availability of other informal caregivers is not known. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. Considering the request for PCA services is for 6 hours per day, 7 days per week, it is reasonable to conclude that there are no informal caregivers who are able to provide care during these hours on a regular basis. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance for daily activities. Providing PCA services daily, and with additional hours per day will provide more support to the patient during hours of the day when she is most active. 

Personal Care Aide services Level 2: 6 hours per day, 7 days per week, for a total of 42 hours per week are medically necessary. The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 6 hours per day, 7 days per week, for a total of 42 hours per week is reversed. Medical necessity is substantiated.