Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, generalized osteoarthritis (OA), unspecified tremors, and urinary incontinence

Treatment is increase in Personal Care Aide services Level 2: 14 hours per day, 7 day(s) per week, a total of 98 hours per week

The insurer denied coverage for an increase in Personal Care Aide services Level 2: 14 hours per day, 7 day(s) per week, a total of 98 hours per week
 
The denial is overturned

This elderly patient has significant functional impairment due to several chronic medical conditions. She lives with her son and receives some informal help from family, but she relies primarily on personal care aide (PCA) services for assistance with activities of daily living (ADLs). The patient has been receiving PCA services 42 hours per week (6 hours per day).

The patient (via designee) requested an increase of PCA services to 98 hours per week (14 hours per day), which was denied. An external appeal was requested.

The most recent Uniform Assessment System (UAS) provided was reviewed. The functional status report indicates that the patient is totally dependent for meal preparation, ordinary housework, shopping; she needs maximal assistance for managing medications, transportation, stairs; extensive assistance for managing finances; limited assistance for phone use. For ADLs (activities of daily living), the patient needs maximal assistance for bathing, personal hygiene, dressing upper and lower body, walking, locomotion; extensive assistance for transfer toilet, toilet use, bed mobility, and eating. Comparison the (prior) UAS with the most recent UAS indicates decline in function for a few ADLs.

Considering the information provided for review, including the patient's medical history and functional limitations, it is medically necessary, and in the patient's best interest to have a caregiver present and available to provide care throughout the day and night in order to prevent adverse health and safety events (e.g., skin damage due to incontinence and pressure; falls/injury); ensure assistance is available for all meals, and to assist with pain relief when needed. 

Assistance from informal caregivers is voluntary as per NYS (New York State) regulations for personal care services. When informal caregivers are unavailable to provide care when needed on a consistent basis, then personal care services are indicated to provide assistance with daily activities, including ADLs that occur at various times of the day and night. The patient has substantial functional impairment and needs help with all daily activities (routine and unscheduled IADLs (independent activites of daily living) and ADLs through the day and night). Request for PCA 14 hours per day is to ensure aide services will be available when an informal caregiver is not present in the home. This plan is consistent with NYS regulations for personal care services.

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 increase in Personal Care Aide services Level 2: 14 hours per day, 7 day(s) per week, for a total of 98 hours per week is overturned. Medical Necessity is substantiated.