Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, peripheral vascular disease, osteoarthritis, and heart failure.

Treatment: Personal Care Aide (PCA) Level 2 Services of 6.5 hours per day, 6 days per week for a total of 39 hours per week.

The insurer denied coverage for PCA Level 2 Services of 6.5 hours per day, 6 days per week for a total of 39 hours per week.

The denial is overturned. 

This is a female patient with substantial functional impairment, who requires assistance with all daily activities. The patient lives alone and has no informal support. She is dependent on personal care aide (PCA) services for all assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She has been receiving PCA services 6.5 hours per day, 5 days per week. The patient reported increased pain in her knees (noted in the insurer's final denial letter). She requested increase of PCA services to 6 days per week.

Uniform Assessment System (UAS) documentation was provided for review. The functional status report indicates the patient needs maximal assistance for all IADLs; except managing finances (extensive assistance), managing medications (limited assistance) and phone use (setup help). The patient needs maximal or extensive assistance for all ADLs. Based on the available records, it appears the patient's need for assistance with IADLs and ADLs is primarily due to her impaired physical function. The cognitive issues identified in the UAS (occasional forgetfulness, some difficulty with decisions in new situations) do not appear to be a significant contributing factor to the difficulties the patient encounters with daily activities as described in the functional status report of the UAS. Based on the available records, it appears the patient has several medical problems which contribute to her functional impairment with daily activities including: stroke, peripheral vascular disease, osteoarthritis, and heart failure. 

Considering the patient's medical history and functional impairment limiting her ability for all daily activities, it is medically necessary to have caregiver assistance for all ADLs, and meal preparation and service every day to help prevent adverse health and safety events, such as falls/injuries due to unassisted mobility, skin damage from inadequate toileting and incontinence care, nutritional decline from inadequate food/fluid intake when she is alone. The UAS does not identify any informal caregivers. The patient's grandchildren are supportive but do not live close to the patient and are unable to provide personal care assistance on a regular basis. As per New York State (NYS) regulations for personal care services, assistance from informal caregivers is voluntary. When informal caregivers 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.

The information in the UAS and the physician's letter of medical necessity supports the need for more than 39 hours per week of PCA services. However, the maximum amount of PCA hours that can be recommended from this review is limited to the hours requested, as documented in the insurer' final adverse determination denial notice; in this case 39 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 the requested Personal Care Aide (PCA) Level 2 Services of 6.5 hours per day, 6 days per week for a total of 39 hours per week is overturned. Medical necessity is substantiated.