Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lance Adams Syndrome

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

The denial is overturned

This is a patient with chronic medical problems including Lance Adams Syndrome (Myoclonus secondary to hypoxia), type 2 diabetes, hypertension, and obesity. The patient lives alone. The patient has had one visit to the emergency department in the past 90 days as a result of a fall at home. The patient has had two falls one with minor injury since their nursing home discharge. Both falls occurred upon going to or returning from the bathroom. The patient's gait has been described as unsteady. The patient has two neurologists and was evaluated by their doctors. The patient's physicians indicate in written statements that the patient has severe neurological impairment likely secondary to hypoxia, shaking and frequent falls, with impaired ability to stand, walk and eat.  

The Uniform Assessment System (UAS) Comprehensive Assessment form was thoroughly reviewed and referenced. The patient's cognitive function is described as minimally impaired with no significant memory loss. The patient needs extensive assistance for weight bearing, upper body dressing, toilet use, medications, and phone use.  The patient needs maximal assistance with bathing, lower body dressing, transportation, meal preparation, shopping, and housekeeping.  The patient's need for extensive assistance with phone use limits their ability to call for emergency help. The patient has no informal helpers although their brother attempts to assist at times.  The patient is also noted to be frequently incontinent of urine.  Given the patient's unsteady gait, frequent urinary incontinence, and recent history of two falls, the patient is considered to be a high falls risk. This finding is confirmed by the patient's physicians.  Personal Assistance Services (PAS) hours are approved primarily to provide hands-on assistance for completion of Instrumental Activities of Daily Living (IADL)/ Activities of Daily Living (ADL) tasks when no one else is available to provide assistance. 
 
From a home care perspective and within a reasonable degree of medical judgment, the carrier's denial of 70 hours per week of PAS services is not medically appropriate  The patient cannot be safely managed with the current 29.5 hours per week. 

The carrier's decision to deny an increase in PAS services should be reversed to allow for 10 hours per day, 7 days per week, for a total of 70 hours per week.  These hours can be used flexibly to best meet the patient's needs, including his need for toileting, dressing, bathing and weight bearing.
 
Based on the above, the insurer's denial must be reversed. 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 aide (PCA) level 2 services: 10 hours per day, 7 days per week, for a total of 70 hours per week is substantiated.