Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, legal blindness, mild intellectual disabilities, and osteoarthritis.
Treatment: Personal Care Assistant (PCA) services, 2 12-hour split shifts, 7 days per week.
The insurer denied coverage for PCA services, 2 12-hour split shifts, 7 days per week.  The denial is overturned.

This female patient with a history of osteoporosis, legal blindness, mild intellectual disabilities, and osteoarthritis. The patient needs assistance for all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She receives personal care assistance (PCA) services 84 hours per week. The patient lives with her mother. Some informal help is provided by the mother and the patient's brother (lives locally). The external appeal application (section 15) indicates patient needs increase of PCA services due to her disability and frequent falls. The patient (via designee) requested PCA services 2 12-hour split shifts, 7 days per week, which was denied. External appeal was requested.

The Uniform Assessment System (UAS) includes diagnosis of legal blindness; UAS section C reports patient is blind; no vision. The cause is not noted, and it is not known at what stage of the patient's life vision impairment occurred. Intellectual disabilities are associated with impaired daily living skills. Research has demonstrated that when people with intellectual disabilities have vision impairment, daily living skills are diminished to a greater extent. 

The patient has cognitive impairment, including significant memory impairment. It is not known to what extent cognitive deficits limit the patient's ability to learn/remember adaptive skills for vision loss. It was noted in the UAS that the patient walks with a cane and extensive assistance. Her need for weight-bearing assistance is most likely due to physical impairment; but she probably also needs a caregiver to provide physical guidance, cues, and re-direction to ensure her safety when she engages in activities that may result in harm due to poor vision (e.g., mobility around her home may result in falls).

The UAS indicates patient has chronic pain, specifically back and leg pain were noted. She has diagnosis of osteoarthritis. Back and lower extremity pain is probably a significant cause of the patient's impaired mobility, including walking (cane and extensive assistance needed) and transfers (UAS indicates patient has difficulty moving to a standing position unassisted, i.e., sit to stand transfer). Back and lower extremity pain can also affect other ADLs, such as bathing and lower body dressing (UAS reports patient has difficulty bending). 

It is medically necessary for the patient to have assistance with mobility, toileting, and incontinence care through the night. This is not stand-alone safety supervision. The patient needs extensive (weight-bearing) assistance for walking, transfers, and toilet use (including incontinence care). These ADLs occur at variable, unscheduled times throughout the day and night.  The high frequency of falls requires a new care plan that provides assistance when needed for all mobility related activities. Absence of a caregiver for 5 hours (when a live-in aide sleeps) does not appear to be compatible with the patient's care needs. 

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 assistance (PCA) services, 2 12-hour split shifts, 7 days per week is overturned. Medical Necessity is substantiated.