Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis and Cognitive impairment.

Treatment: Personal Care Assistant (PCA) services at 7 days x 12 hours (84 hours) per week.

The insurer denied coverage for PCA services at 7 days x 12 hours (84 hours) per week.

The denial is overturned.

This is female patient who resides in an assisted living facility (ALF).  She has various medical conditions affecting her functional status resulting in dependence on caregiver support for all activities of daily living (ADLs) and instrumental activities of daily living (IADLs).  Her medical history includes: osteoarthritis and cognitive impairment. Services provided by staff at the ALF include meal preparation, housekeeping, and medication administration.  The patient is approved for personal care assistant (PCA) services 7 hours per day, 7 days per week to help with ADLs.  The patient's daughter requested an increase of PCA services to 12 hours per day, 7 days per week.

The most recent Uniform Assessment System (UAS) report indicates the patient's functional status for IADLs includes total dependence for all household related tasks, meal preparation, shopping and finances; and maximal or extensive assistance for all other IADLs.  The patient needs extensive assistance for most ADLs except for personal hygiene (limited assistance) and bed mobility, eating (supervision).  Based on the UAS, physician's notes and daughter's letter, it appears the patient is cognitively impaired to the extent that it affects some aspects of her daily function.  Considering the patient's cognitive and physical functional status, it is apparent that the patient needs substantial assistance for most daily activities.  Therefore, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day to provide assistance with daily activities.  In the insurer's final denial letter, it was noted that the request for increase of PCA services is unrelated to PCA tasks and is considered safety monitoring which is not a covered service. Based on the UAS, physician and Physical Therapy notes and the daughter's letter, it is apparent the patient needs assistance with ADLs throughout the day.  This is not stand-alone safety supervision. Providing safety precautions during ADL care is part of the scope of practice for personal care services.  Without adequate assistance, the patient is at risk for various adverse health and safety consequences such as: falls and injury; incontinence associated skin damage; malnutrition and dehydration. 

There is one informal caregiver identified in the UAS, and it appears the informal caregiver provides limited assistance with some IADLs.  The patient needs additional ADL support each day beyond the current 7 hours of PCA services.  Assistance from informal caregivers is voluntary as per New York State regulations for personal care services.  Considering the daughter is requesting increase of PCA services to 12 hours per day, 84 hours per week, it is reasonable to conclude that there are no informal caregivers available to assist the patient for additional hours before or after the 7 hour PCA shift.  When informal caregivers are not available to provide necessary support for daily activities, then personal care services are indicated to provide assistance for all IADLs and ADLs when needed throughout the day. 

The maximum number of PCA hours that can be approved from this review is limited by the number of hours requested; in this case 84 hours per week. 

Personal Care Assistant services 7 days per week, 12 hours per day, total of 84 hours per week is medically necessary.

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

The carrier's denial of coverage for Personal Care Assistant (PCA) services at 7 days x 12 hours (84 hours) per week is overturned.  The medical necessity is substantiated.