Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, congestive heart failure (CHF), vertigo, hypertension, hidradenitis suppurativa, hyperlipidemia, ischemic cardiomyopathy, neuralgia, obesity, plantar fascial fibromatosis, hernia, and glaucoma
Treatment: Personal care assistance (PCA) services 40 hours per week
The insurer denied coverage for PCA services 40 hours per week
The denial is overturned
 
This adult patient has extensive medical history associated with functional impairment which limits his ability to perform daily activities. The patient lives alone. The Uniform Assessment System (UAS) indicates there are no informal helpers. The patient relies on PCA services to assist him with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). As per the UAS, the patient was receiving PCA services 25 hours per week, 4 days per week (3 days for 6 hours; 1 day for 7 hours). The external appeal application includes comments from the patient indicating that he has increased difficulty with ADLs; increased pain; difficulty walking. The patient requested increase of PCA services to 7 days per week with increase of hours to 40 per week, which was denied; but the plan increased PCA services to 27 hours per week. External appeal was requested.

The most recent UAS provided was reviewed. The functional status report for IADLs indicates the patient needs maximal assistance for meal preparation, ordinary housework, shopping; extensive assistance for managing medications, stairs, transportation, equipment management; setup help for managing finances, phone use. For ADLs, the patient needs extensive assistance for bathing, dressing lower body; limited assistance for personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use; independent setup help for bed mobility, eating.

With consideration of all the issues impacting the patient's health and safety, it is medically necessary, and in the patient's best interest to have caregiver assistance on a daily basis. The patient needs help every day with mobility, all personal care ADLs, meals, medications, and some housekeeping tasks. 

PCA 27 hours per week (currently approved services) allocated over 7 days per week (average of less than 4 hours per day) is insufficient to meet the patient's daily care needs. The patient had been receiving PCA services in the morning and part of the afternoon; the new schedule with 40 hours per week may be able to provide some help in the evening (e.g., evening shift for dinner, medications, evening ADLs). Managed Long Term Care (MLTC) 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. Based on the information provided for review, the patient needs assistance every day with routine ADLs/IADLs and unscheduled and/or recurring ADLs/IADLs (e.g., toileting, mobility, medications, meals). Additional PCA hours would not be for safety supervision. The patient needs assistance to ensure safe, effective completion of ADLs and IADLs that occur throughout the day, every day as discussed in this review.  

As per the UAS, the patient has no informal help, so personal care services are indicated to provide the patient with necessary assistance for ADLs and IADLs. Increasing PCA services to 40 hours per week will expand the time the patient can have assistance with daily activities throughout the week. 

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 personal care assistance (PCA) services 40 hours per week is substantiated.