Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive decline and chronic pain. 

Treatment: Personal Care Assistance (PCA) services of 8 hours per day, 7 days per week for a total of 56 hours per week. 

The insurer denied coverage for PCA services of 8 hours per day, 7 days per week for a total of 56 hours per week. 

The denial is overturned. 

This is a female patient with a past medical history of cognitive decline, osteoporosis, hypertension, obesity, anemia, chronic pain, fatigue, joint pain, abnormal gait and mobility, hearing loss, osteoarthritis, vitamin D deficiency and cataract surgery. The patient has several medical conditions contributing to functional decline. There is no one home with the patient during the day except for the personal care assistant.  She receives personal care assistance (PCA) 40 hours per week; provided as afternoon services, 7 days per week. An increase of services to 56 hours per week, 8 hours per day was requested. Uniform Assessment System (UAS) documentation was provided for review. The patient's functional status included maximal assistance or total dependence for housework, meal preparation and shopping; all other instrumental activities of daily living (IADLs) needed extensive assistance.  For activities of daily living (ADLs), the patient needed extensive assistance for bathing and lower body dressing; limited assistance for all other ADLs, except bed mobility and eating (independent, setup help). 

Considering the patient's medical history, functional status and living situation the patient needs assistance with multiple daily activities; and with no informal help at home for most of the day, she is dependent on personal care services for assistance with most or all daily activities. She needs assistance with all IADLs.  This includes preparation and service of all 3 meals per day to ensure the patient is not skipping meals due to inability to prepare/serve a meal, or forgetting to eat.  She needs ADL assistance for bathing daily; and personal hygiene and dressing morning and evening.  She needs assistance for toileting which occurs at various unscheduled times of the day, including the hours before and after the aide leaves. The patient's mobility has declined (as reported by the daughter and physician), and she needs help with transfers and walking around her home to help decrease occurrence of falls. With progressive cognitive decline, the patient most likely needs some verbal cueing/prompting in addition to physical assistance to ensure safe performance of mobility and other ADLs.  

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services are indicated to provide necessary assistance to the patient for daily activities, including ADLs that occur at various and unscheduled times through the day and night. In this case, the patient needs assistance with ADLs and IADLs at various times from morning until evening. The request for an increase of services is for 56 hours per week, 8 hours per day. This may be sufficient; but if PCA services are provided as 8 continuous hours, there may be limited time either in the morning or in the evening to ensure the patient finishes breakfast and dinner and that assistance is provided for all morning and evening ADLs.  Splitting the hours may be an option to extend morning or evening assistance, though this would leave the patient alone for a period of time in the afternoon. Optimal PCA schedule can be determined with the patient and family.  

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The insurer's denial of coverage for the requested PCA services of 8 hours per day, 7 days per week for a total of 56 hours per week is overturned. The medical necessity is substantiated.