Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colon cancer, coronary heart disease, osteoporosis.

Treatment: Personal care aide (PCA) services Level 2 of 10 hours per day, 7 days per week for a total of 70 hours per week.

The insurer denied coverage for personal care aide (PCA) services Level 2 of 10 hours per day, 7 days per week for a total of 70 hours per week.

The denial is overturned.

This patient has experienced progressive functional decline associated with several medical conditions. The patient had been approved for personal care aide (PCA) services 4 hours per day, 2 days per week for assistance with ADLs (activities of daily living) and IADLs (independent activities of daily living). Request was made (via designee) to increase PCA services to 10 hours per day, 7 days per week, which was denied. 

The patient has significant cardiac disease. Transthoracic echocardiogram showed severe aortic stenosis. She had TAVR (transcatheter aortic valve replacement) procedure several months ago. TAVR is generally recommended for elderly patients with severe AS (aortic stenosis) who are high risk for surgical aortic valve replacement. As severity of AS increases, patients develop symptoms of chest pain and heart failure. The UAS (Uniform Assessment System) indicates the patient has occasional chest pain. She had some symptoms of heart failure including dyspnea (with moderate activity), fatigue to the extent that she is unable to finish usual daily activities, and intermittent lower extremity edema. 

The most recent UAS reports patient needs supervision for toilet transfer and limited assistance for toilet use. This may not be high level assistance, but it indicates a significant change within 3 months. In the UAS the patient was independent for toilet transfer and toilet use. The need for assistance with toileting is a significant change, as toileting occurs at various and recurring times throughout the day. As previously noted, the aide needs to help guide the patient's hands for proper cleaning (likely due to patient's impaired hand function), and also assist with clothing adjustment. The need for supervision with toilet transfer raises a question. The UAS indicates the patient has frequent difficulty moving to a standing position unassisted (sit to stand transfer). Nursing comments indicate aide provides oversight during transfers (including toilet) due to poor balance to ensure safety. If the patient has difficulty standing up and is unsteady due to poor balance, it is unclear how supervision helps. When the patient is unsteady during transfer, it is reasonable to expect the aide provides at least limited assistance to help stabilize the patient to prevent a fall. 

MLTC (managed long-term care plan) 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. Therefore, all the patient's care needs every day and throughout the day must be considered in the determination of the patient's personal care service hours. The patient's need for additional services is not for stand-alone safety supervision. She needs a caregiver to help ensure proper and safe completion of ADLs and IADLs. Therefore, it is medically necessary for the patient to have a caregiver present every day and for extended hours during the day to assist with tasks that occur at routine or unscheduled and/or recurring times of the day (meal preparation/service, bathing, dressing, toileting, mobility).
Recommendation is given to approve Personal Care Aide services Level 2: 10 hours per day, 7 days per week; total of 70 hours per week. 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 Personal Care Aide (PCA) Services Level 2 of 10 hours per day, 7 days per week for a total of 70 hours per week is overturned. Medical Necessity is substantiated.